Provider Demographics
NPI:1285376087
Name:GOMEZ, DESTINI RAE
Entity type:Individual
Prefix:
First Name:DESTINI
Middle Name:RAE
Last Name:GOMEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 RODEO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6816
Mailing Address - Country:US
Mailing Address - Phone:505-982-2129
Mailing Address - Fax:
Practice Address - Street 1:1264 RODEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6816
Practice Address - Country:US
Practice Address - Phone:505-982-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM60815208D00000X, 363L00000X, 163W00000X, 207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine