Healthcare Provider Details

I. General information

NPI: 1598196198
Provider Name (Legal Business Name): MYRON JAVON FALKNER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR STE 310
GRESHAM OR
97030-3774
US

IV. Provider business mailing address

1700 NW CIVIC DR STE 310
GRESHAM OR
97030-3774
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax:
Mailing address:
  • Phone: 503-666-8832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202108339NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: