Provider Demographics
NPI:1538261375
Name:WAGNER, TYLR AUSTIN (PMHNP)
Entity type:Individual
Prefix:
First Name:TYLR
Middle Name:AUSTIN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8605 SE ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4738
Mailing Address - Country:US
Mailing Address - Phone:971-246-1943
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3713
Practice Address - Country:US
Practice Address - Phone:360-397-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507408RN163W00000X
WAAP60776226363LP0808X
OR201706858NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse