Provider Demographics
NPI:1275181265
Name:GOMEZ, RACHEL MICHELE (PA)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MICHELE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:MICHELE
Other - Last Name:BAUTSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-985-1925
Mailing Address - Fax:239-468-7929
Practice Address - Street 1:16271 BASS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3616
Practice Address - Country:US
Practice Address - Phone:239-985-1925
Practice Address - Fax:239-468-7929
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9112472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104363500Medicaid