Provider Demographics
NPI:1174990188
Name:GOMEZ, PETRA G (NCPT, NCMA)
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:G
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:NCPT, NCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CALLE DE LAS SONATAS
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2886
Mailing Address - Country:US
Mailing Address - Phone:949-632-5316
Mailing Address - Fax:
Practice Address - Street 1:1300 AVENIDA VISTA HERMOSA
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6315
Practice Address - Country:US
Practice Address - Phone:949-218-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy