Healthcare Provider Details

I. General information

NPI: 1538261375
Provider Name (Legal Business Name): TYLR AUSTIN WAGNER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 4TH PLAIN BLVD
VANCOUVER WA
98661-3713
US

IV. Provider business mailing address

8605 SE ELLIS ST
PORTLAND OR
97266-4738
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8488
  • Fax:
Mailing address:
  • Phone: 971-246-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201507408RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60776226
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201706858NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: