Provider Demographics
NPI:1588635098
Name:USA MEDDAC,RWBAHC
Entity Type:Organization
Organization Name:USA MEDDAC,RWBAHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:520-533-0757
Mailing Address - Street 1:3384 GOLDEN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-6661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW RD
Practice Address - Street 2:
Practice Address - City:FT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613-5080
Practice Address - Country:US
Practice Address - Phone:520-533-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN082077261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient