Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | RN236233 | GA |
NPI | 1003371790 |
---|---|
Provider Name | Ana Alicia Gomez Nova |
First Address | Tifton, GA 31793-8200 |
Second Address | Tifton, GA 31793-8200 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2019 |
Last Update Date | 23/01/2020 |