Provider Demographics
NPI:1275746281
Name:JANSE, PETER ANDREW (IDC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ANDREW
Last Name:JANSE
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 1:16 HUTCHINS ST
Mailing Address - Street 2:
Mailing Address - City:SANTA RITA
Mailing Address - State:GU
Mailing Address - Zip Code:96915-1119
Mailing Address - Country:US
Mailing Address - Phone:671-333-4202
Mailing Address - Fax:
Practice Address - Street 1:PSC 455
Practice Address - Street 2:BOX 191
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96540-9998
Practice Address - Country:US
Practice Address - Phone:671-333-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman