Provider Demographics
NPI:1659825651
Name:LYSTRUP, NATHAN GREY (FNP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:GREY
Last Name:LYSTRUP
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-1721
Mailing Address - Country:US
Mailing Address - Phone:702-596-4157
Mailing Address - Fax:
Practice Address - Street 1:450 TATONE ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818-8076
Practice Address - Country:US
Practice Address - Phone:541-481-7212
Practice Address - Fax:541-481-2020
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201605982RN163W00000X
OR201605983NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse