Basic Information
| Provider Information | |||||||||
| NPI: | 1538261375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | TYLR | ||||||||
| MiddleName: | AUSTIN | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8605 SE ELLIS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972664738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712461943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 E 4TH PLAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986613713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603978488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201507408RN | OR | N | Nursing Service Providers | Registered Nurse | 363LP0808X | AP60776226 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201706858NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.