Provider Demographics
NPI:1053008607
Name:GOMEZ MORALES, KEVELYN GERALDINE
Entity type:Individual
Prefix:
First Name:KEVELYN
Middle Name:GERALDINE
Last Name:GOMEZ MORALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16611 LIVE OAK CANYON DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-7886
Mailing Address - Country:US
Mailing Address - Phone:832-250-9365
Mailing Address - Fax:
Practice Address - Street 1:16611 LIVE OAK CANYON DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-7886
Practice Address - Country:US
Practice Address - Phone:832-250-9365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant