Healthcare Provider Details

I. General information

NPI: 1336854504
Provider Name (Legal Business Name): JUSTIN ANTHONY GOMEZ FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 11/23/2025
Certification Date: 11/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 TOM TENNANT DR
WOODBURN OR
97071-2828
US

IV. Provider business mailing address

3187 E 3050 S
SAINT GEORGE UT
84790-1372
US

V. Phone/Fax

Practice location:
  • Phone: 971-345-4767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10050797
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number863840
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: