Provider Demographics
NPI:1750806121
Name:GOMEZ, CARSON CHANELL
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:CHANELL
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARSON
Other - Middle Name:CHANELL
Other - Last Name:DAVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-2111
Mailing Address - Country:US
Mailing Address - Phone:406-303-9781
Mailing Address - Fax:949-703-7587
Practice Address - Street 1:212 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-2111
Practice Address - Country:US
Practice Address - Phone:406-303-9781
Practice Address - Fax:949-703-7587
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT196690363LA2200X
NVRN79877363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health