Healthcare Provider Details

I. General information

NPI: 1982223251
Provider Name (Legal Business Name): TIMOTHY M GOCO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N EUCLID AVE STE B
UPLAND CA
91786-8323
US

IV. Provider business mailing address

300 N EUCLID AVE STE B
UPLAND CA
91786-8323
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-9100
  • Fax:
Mailing address:
  • Phone: 909-920-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95014117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: