Healthcare Provider Details

I. General information

NPI: 1003969643
Provider Name (Legal Business Name): ANDREW E VILIUS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 NE 3RD ST
GRESHAM OR
97030-7418
US

IV. Provider business mailing address

955 NE 3RD ST
GRESHAM OR
97030-7418
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5896
  • Fax:
Mailing address:
  • Phone: 503-491-5896
  • Fax: 888-972-9783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200750075NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number200341326RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: