Provider Demographics
NPI:1053575829
Name:GOMEZ, TASHIKA (PNP)
Entity type:Individual
Prefix:MS
First Name:TASHIKA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 S ALVORD ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-2720
Mailing Address - Country:US
Mailing Address - Phone:315-435-4210
Mailing Address - Fax:315-435-4993
Practice Address - Street 1:9611 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2334
Practice Address - Country:US
Practice Address - Phone:954-924-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017209363L00000X, 363LP0200X
NY382654363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner