Healthcare Provider Details

I. General information

NPI: 1982378543
Provider Name (Legal Business Name): DIEGO HUGO GONZALEZ FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12921 S VISTA STATION BLVD
DRAPER UT
84020-2376
US

IV. Provider business mailing address

1055 N 500 W ATTN CREDENTIALING
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-687-1020
  • Fax:
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10222776-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number10222776-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: