Healthcare Provider Details

I. General information

NPI: 1851103402
Provider Name (Legal Business Name): MR. GARY LYNN HUNTER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 NW EASTMAN PKWY STE 175
GRESHAM OR
97030-3859
US

IV. Provider business mailing address

1550 NW EASTMAN PKWY STE 175
GRESHAM OR
97030-3859
US

V. Phone/Fax

Practice location:
  • Phone: 503-610-3852
  • Fax:
Mailing address:
  • Phone: 503-610-3852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number113166
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: