Provider Demographics
NPI:1902441959
Name:MYERS, MICHAEL JOSEPH (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MYERS
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-0047
Mailing Address - Country:US
Mailing Address - Phone:971-368-1980
Mailing Address - Fax:541-550-2908
Practice Address - Street 1:36641 SE LUSTED RD
Practice Address - Street 2:
Practice Address - City:BORING
Practice Address - State:OR
Practice Address - Zip Code:97009-9717
Practice Address - Country:US
Practice Address - Phone:541-295-5172
Practice Address - Fax:971-362-4818
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10015393363LP0808X
OR201509534RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health