Provider Demographics
NPI:1821079526
Name:PAYNE, GREGORY TODD
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:TODD
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
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:96205-0054
Mailing Address - Country:KR
Mailing Address - Phone:0118227-917-8110
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDCOM
Practice Address - Street 2:ATTN DCCS-QM
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-0054
Practice Address - Country:KR
Practice Address - Phone:0118227-917-8110
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI164W00000X164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse