Healthcare Provider Details

I. General information

NPI: 1659825651
Provider Name (Legal Business Name): NATHAN GREY LYSTRUP F.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 TATONE ST
BOARDMAN OR
97818-8076
US

IV. Provider business mailing address

1967 NE 2ND ST
HERMISTON OR
97838-1721
US

V. Phone/Fax

Practice location:
  • Phone: 541-481-7212
  • Fax: 541-481-2020
Mailing address:
  • Phone: 702-596-4157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201605982RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201605983NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: