=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275041477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHINICHI DAIMYO PMHNP-BC, CRNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2018
-----------------------------------------------------
Last Update Date | 12/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 132 E BROADWAY STE 810
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97401-3160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-357-9433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 ALWARD RD
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02132-7703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-237-0455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 101.0134731
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP61136881
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 084400-23
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN2323354
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP211039
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | SP019201
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN1061501
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | F403863-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 202112981NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------