Provider Demographics
NPI:1104386929
Name:MORALES, NICHOLIS
Entity Type:Individual
Prefix:
First Name:NICHOLIS
Middle Name:
Last Name:MORALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NMRTC OKINAWA
Mailing Address - Street 2:PSC 482
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NMRTC OKINAWA
Practice Address - Street 2:PSC 482
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362
Practice Address - Country:US
Practice Address - Phone:619-721-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 390200000X
VA0101270857208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program