Provider Demographics
NPI:1275041477
Name:DAIMYO, SHINICHI (PMHNP-BC, CRNP)
Entity Type:Individual
Prefix:MR
First Name:SHINICHI
Middle Name:
Last Name:DAIMYO
Suffix:
Gender:M
Credentials:PMHNP-BC, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ALWARD RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02132-7703
Mailing Address - Country:US
Mailing Address - Phone:617-237-0455
Mailing Address - Fax:
Practice Address - Street 1:132 E BROADWAY STE 810
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3160
Practice Address - Country:US
Practice Address - Phone:541-357-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134731363LP0808X
WAAP61136881363LP0808X
NH084400-23363LP0808X
MARN2323354363LP0808X
MECNP211039363LP0808X
PASP019201363LP0808X
DCRN1061501363LP0808X
NYF403863-01363LP0808X
OR202112981NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health