Basic Information
Provider Information
NPI: 1033556717
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GOMEZ
FirstName: SANDRA
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: NP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 633 RTE 37 W
Address2:  
City: TOMS RIVER
State: NJ
PostalCode: 087558007
CountryCode: US
TelephoneNumber: 7322404787
FaxNumber: 7325751597
Practice Location
Address1: 633 RTE 37 W
Address2:  
City: TOMS RIVER
State: NJ
PostalCode: 087558007
CountryCode: US
TelephoneNumber: 7322404787
FaxNumber: 7325751597
Other Information
ProviderEnumerationDate: 06/04/2013
LastUpdateDate: 02/16/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
364SA2200X26NR11928000NJY Physician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health

No ID Information.


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