Provider Demographics
NPI:1396817565
Name:TWILLEAGER, STEVEN WYATT (IDC)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:WYATT
Last Name:TWILLEAGER
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:NAVAL COASTAL WARFARE SQUADRON FIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL COASTAL WARFARE SQUADRON FIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135
Practice Address - Country:US
Practice Address - Phone:619-437-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman