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General NPI Number Information
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NPI Number | 1407231244
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Entity Type | Individual
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Provider Name | ROBERT DIDERICKSEN PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 07/22/2015
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Last Update Date | 11/04/2021
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Provider Practice Location Address
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Address Line | 1501 PEARL ST
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City | EUGENE
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State | OR
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Zip | 97401-4010
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Country | US
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Telephone | 541-342-8437
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Fax |
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Provider Business Mailing Address
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Address Line | 1258 HIGH ST
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City | EUGENE
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State | OR
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Zip | 97401-3238
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Country | US
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Telephone | 541-342-8437
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 0995173
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License Number State | CO
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