Provider Demographics
NPI:1518101245
Name:LOOMAN, DANE A (IDMT)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:A
Last Name:LOOMAN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 BOMBER RD
Mailing Address - Street 2:726 ACS/SG
Mailing Address - City:MOUNTAIN HOME A F B
Mailing Address - State:ID
Mailing Address - Zip Code:83648-5272
Mailing Address - Country:US
Mailing Address - Phone:208-828-3604
Mailing Address - Fax:208-828-3616
Practice Address - Street 1:84 BOMBER RD
Practice Address - Street 2:726 ACS/SG
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-5272
Practice Address - Country:US
Practice Address - Phone:208-828-3604
Practice Address - Fax:208-828-3616
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians