Basic Information
| Provider Information | |||||||||
| NPI: | 1992720486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | ALMA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMEZ-VAN ALLMAN | ||||||||
| OtherFirstName: | ALMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | STE 170 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565020 | ||||||||
| FaxNumber: | 4256565019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 05/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60231468 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | G8925755 | 01 | WA | MEDICARE W VALLEY MEDICAL GROUP - RENTON | OTHER | 2015880 | 05 | WA | MEDICAID |