Provider Demographics
NPI:1063460210
Name:GERVACIO, NEILROSE LACISTE (IDC)
Entity Type:Individual
Prefix:MR
First Name:NEILROSE
Middle Name:LACISTE
Last Name:GERVACIO
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:PSC 557 BOX 2631
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CAMP SCHWAB BMC
Practice Address - Street 2:3D MED BN, 3D MLG, C CO
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96604
Practice Address - Country:US
Practice Address - Phone:01181611-725-2272
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710I1002XOtherINDEPENDENT DUTY CORPSMAN