Provider Demographics
NPI:1952754442
Name:JOHNSON, NATHAN PATRICK (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:PATRICK
Last Name:JOHNSON
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 12926
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-0926
Mailing Address - Country:US
Mailing Address - Phone:971-304-9306
Mailing Address - Fax:503-926-6624
Practice Address - Street 1:4035 12TH ST CUTOFF SE STE 120
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:971-304-9306
Practice Address - Fax:503-926-6624
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN209338163W00000X
OR201701389RN163WP0808X
OR201701390NPPP2084P0800X
TN0000022011363LP0808X
OR201701390NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1952754442OtherPECO, NPPES