Healthcare Provider Details

I. General information

NPI: 1427527886
Provider Name (Legal Business Name): STASIS PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 12TH ST CUTOFF SE STE 120
SALEM OR
97302-1754
US

IV. Provider business mailing address

PO BOX 12926
SALEM OR
97309-0926
US

V. Phone/Fax

Practice location:
  • Phone: 971-304-9306
  • Fax: 503-926-6624
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: NATHAN PATRICK JOHNSON
Title or Position: OWNER
Credential: MSN
Phone: 971-304-9306