Healthcare Provider Details

I. General information

NPI: 1386290773
Provider Name (Legal Business Name): NICHOLAS A WHITE PMHNP-BC, MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 WILLAMETTE ST
EUGENE OR
97405-3348
US

IV. Provider business mailing address

3203 WILLAMETTE ST
EUGENE OR
97405-3348
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-9912
  • Fax:
Mailing address:
  • Phone: 541-726-9912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number212520
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1386290773
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: