Provider Demographics
NPI:1023407897
Name:GOMORY, STELLA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:MARIE
Last Name:GOMORY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 E GLENDORA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-2840
Mailing Address - Country:US
Mailing Address - Phone:714-878-9473
Mailing Address - Fax:
Practice Address - Street 1:1720 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2414
Practice Address - Country:US
Practice Address - Phone:323-268-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-17
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant