Provider Demographics
NPI:1881356368
Name:GOUCHER, JUSTIN (APRN)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GOUCHER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SELLAND LN
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-5568
Mailing Address - Country:US
Mailing Address - Phone:870-225-6219
Mailing Address - Fax:
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1944
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216579363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology