Basic Information
| Provider Information | |||||||||
| NPI: | 1720033376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | GENE | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 E PIONEER | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983723265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536978400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4238 AUBURN WAY N | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980021311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538767600 | ||||||||
| FaxNumber: | 2538767610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 8526911-1205 | UT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD60480708 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1720033376 | 05 | UT | MEDICAID |