Healthcare Provider Details

I. General information

NPI: 1063299717
Provider Name (Legal Business Name): JUSTIN MORA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 S STRATFORD AVE STE B
SANTA MARIA CA
93454-5908
US

IV. Provider business mailing address

2271 S DEPOT ST
SANTA MARIA CA
93455-1216
US

V. Phone/Fax

Practice location:
  • Phone: 805-332-8446
  • Fax: 805-332-8483
Mailing address:
  • Phone: 805-922-0561
  • Fax: 805-922-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95027200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: