Healthcare Provider Details

I. General information

NPI: 1982853784
Provider Name (Legal Business Name): COLIN ANGUS MCINNES JR. PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 10TH ST
THE DALLES OR
97058-4377
US

IV. Provider business mailing address

3415 SE POWELL BLVD
PORTLAND OR
97202-3371
US

V. Phone/Fax

Practice location:
  • Phone: 503-234-9591
  • Fax:
Mailing address:
  • Phone: 503-234-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200241682RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200850088NP FNP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: