Provider Demographics
NPI:1689251290
Name:PASTIRIK, TREY MICHAEL (IDC)
Entity Type:Individual
Prefix:
First Name:TREY
Middle Name:MICHAEL
Last Name:PASTIRIK
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:HM SMITH BLVD
Mailing Address - Street 2:BLDG 309A
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547
Mailing Address - Country:US
Mailing Address - Phone:910-450-4357
Mailing Address - Fax:
Practice Address - Street 1:FC309B H M SMITH BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28539
Practice Address - Country:US
Practice Address - Phone:210-823-4172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program