Provider Demographics
NPI:1982853784
Name:MCINNES, COLIN ANGUS JR (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:COLIN
Middle Name:ANGUS
Last Name:MCINNES
Suffix:JR
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 1:3415 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3371
Mailing Address - Country:US
Mailing Address - Phone:503-234-9591
Mailing Address - Fax:
Practice Address - Street 1:3601 W 10TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-4377
Practice Address - Country:US
Practice Address - Phone:503-234-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200241682RN163W00000X
OR200850088NP FNP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218112Medicaid
OR218112Medicaid