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General NPI Number Information
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NPI Number | 1538261375
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Entity Type | Individual
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Provider Name | TYLR AUSTIN WAGNER PMHNP
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Gender | Male
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Dates
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Enumeration Date | 09/02/2006
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Last Update Date | 10/02/2017
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Provider Practice Location Address
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Address Line | 1601 E 4TH PLAIN BLVD
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City | VANCOUVER
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State | WA
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Zip | 98661-3713
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Country | US
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Telephone | 360-397-8488
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Fax |
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Provider Business Mailing Address
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Address Line | 8605 SE ELLIS ST
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City | PORTLAND
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State | OR
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Zip | 97266-4738
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Country | US
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Telephone | 971-246-1943
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 201507408RN
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP60776226
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 201706858NP-PP
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License Number State | OR
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