Individual
TYLR AUSTIN WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PMHNP
Contact information
Practice address
1601 E 4TH PLAIN BLVD, VANCOUVER, WA 98661-3713
(360) 397-8488
Mailing address
8605 SE ELLIS ST, PORTLAND, OR 97266-4738
(971) 246-1943
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
201507408RN
OR
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
201706858NP-PP
OR
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
AP60776226
WA
Other
Enumeration date
09/02/2006
Last updated
10/02/2017
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