Provider Demographics
NPI:1699892554
Name:GOMEZ, AMBROSIO NARVASA (PT)
Entity type:Individual
Prefix:MR
First Name:AMBROSIO
Middle Name:NARVASA
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 73RD ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1705
Mailing Address - Country:US
Mailing Address - Phone:718-478-2864
Mailing Address - Fax:
Practice Address - Street 1:7312 35TH AVE
Practice Address - Street 2:SUITE AA
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-4241
Practice Address - Country:US
Practice Address - Phone:718-458-0616
Practice Address - Fax:718-458-0525
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02557019Medicaid
NYQ01B91Medicare ID - Type Unspecified