1427527886 NPI number — STASIS PSYCHIATRY, LLC

Table of content: (NPI 1427527886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427527886 NPI number — STASIS PSYCHIATRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STASIS PSYCHIATRY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NATHAN JOHNSON, PMHNP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427527886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12926
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97309-0926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4035 12TH ST CUTOFF SE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97302-1754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-304-9306
Provider Business Practice Location Address Fax Number:
503-926-6624
Provider Enumeration Date:
11/15/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
971-304-9306

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1952754442 . This is a "NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 500735377 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".