Provider Demographics
NPI:1790919777
Name:KERCKHOFF, PAUL ERIK (AIR FORCE IDMT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ERIK
Last Name:KERCKHOFF
Suffix:
Gender:M
Credentials:AIR FORCE IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5998 KAMIAKIN TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-2210
Mailing Address - Country:US
Mailing Address - Phone:509-290-6206
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8704
Practice Address - Country:US
Practice Address - Phone:509-247-5755
Practice Address - Fax:509-247-8833
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZB0441656247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other