| Doctor Name: | TYLR AUSTIN WAGNER |
| NPI Number: | 1538261375 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | QMHP |
| License Number: | 201507408RN |
| Business Practice Address: | 4101 Ne Division St Gresham, OR - 970304617 |
| Business Phone Number: | 5036666575 |
| Business Fax Number: | |
| Mailing Address: | 8605 Se Ellis St, PORTLAND |
| State: | OR |
| Postal Code: | 972664738 |
| Phone Number: | 9712461943 |
| Fax Number: | |
| NPI Enumeration Date: | 09/02/2006 |
| NPI Last Update Date: | 05/11/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 163W00000X |
| License Number: | 201507408RN |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Registered Nurse |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) A registered nurse is a person qualified by graduation from an accredited nursing school (depending upon schooling, a registered nurse may receive either a diploma from a hospital program, an associate degree in nursing (A.D.N.) or a Bachelor of Science degree in nursing (B.S.N.), who is licensed or certified by the state, and is practicing within the scope of that license or certification. R.N. |