Provider Demographics
NPI:1962923375
Name:GOMEZ HERNANDEZ, MARIO MICHEL (APRN)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:MICHEL
Last Name:GOMEZ HERNANDEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2513
Mailing Address - Country:US
Mailing Address - Phone:305-243-2424
Mailing Address - Fax:
Practice Address - Street 1:5555 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2513
Practice Address - Country:US
Practice Address - Phone:305-243-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-53906103K00000X
FLAPRN11027912363LF0000X
FL17-360246ZC0007X
FL11027912363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant