=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275939043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEASEL WAYNE EVANS RN, MSN, PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21900 WILLAMETTE DR STE 202
-----------------------------------------------------
City | WEST LINN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97068-3284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-653-0631
-----------------------------------------------------
Fax | 503-653-1464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21900 WILLAMETTE DR STE 202
-----------------------------------------------------
City | WEST LINN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97068-3284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-653-0631
-----------------------------------------------------
Fax | 503-653-1464
-----------------------------------------------------
=====================================================
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 | 201709151NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WP0807X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 201406240RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------