Provider Demographics
NPI:1760419642
Name:MODGLIN, PATRICK ADRIEL (IDC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:ADRIEL
Last Name:MODGLIN
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 1:245 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4063
Mailing Address - Country:US
Mailing Address - Phone:757-925-7929
Mailing Address - Fax:
Practice Address - Street 1:USS CAPE ST GEORGE CG 71
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09566-1191
Practice Address - Country:UM
Practice Address - Phone:757-925-7929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman