Basic Information
| Provider Information | |||||||||
| NPI: | 1366859175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMES | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8459 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972078459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4212 SE DIVISION ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 07/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 201403830RN | OR | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.