Provider Demographics
NPI:1538205281
Name:RIAT, DEJUANA LYNETTE (PA-C)
Entity type:Individual
Prefix:
First Name:DEJUANA
Middle Name:LYNETTE
Last Name:RIAT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18TH MEDCOM
Mailing Address - Street 2:ATTN DCCS-QM (CREDENTIALS)
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205
Mailing Address - Country:KR
Mailing Address - Phone:0118227-916-6027
Mailing Address - Fax:0118227-917-8110
Practice Address - Street 1:D CO 168TH MED BN
Practice Address - Street 2:BOX 36-B CAMP WALKER
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96218
Practice Address - Country:KR
Practice Address - Phone:1225-709-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1038258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant