Healthcare Provider Details

I. General information

NPI: 1972644250
Provider Name (Legal Business Name): CHARLES D HYDE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 N MAIN ST
MOUNT ANGEL OR
97362-9518
US

IV. Provider business mailing address

690 N MAIN ST
MOUNT ANGEL OR
97362-9518
US

V. Phone/Fax

Practice location:
  • Phone: 503-845-2000
  • Fax: 503-845-2384
Mailing address:
  • Phone: 503-845-2000
  • Fax: 503-845-2384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP576A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: