Provider Demographics
NPI:1043752066
Name:TRENT, PHILIP (IDC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:TRENT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 KILMARNOCK CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4083
Mailing Address - Country:US
Mailing Address - Phone:704-619-8656
Mailing Address - Fax:
Practice Address - Street 1:USS O'KANE
Practice Address - Street 2:DDG,BOX 1, UNIT 100189
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96674
Practice Address - Country:US
Practice Address - Phone:808-471-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman