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General NPI Number Information
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NPI Number | 1528452901
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Entity Type | Individual
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Provider Name | JUSTIN WOMOCK BRUNO
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Gender | Male
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Dates
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Enumeration Date | 03/24/2015
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Last Update Date | 01/15/2026
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Provider Practice Location Address
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Address Line | 19500 SE STARK ST
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City | PORTLAND
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State | OR
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Zip | 97233-5757
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Country | US
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Telephone | 800-813-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 500 NE MULTNOMAH ST STE 100
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City | PORTLAND
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State | OR
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Zip | 97232-2031
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DO189652
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License Number State | OR
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