Provider Demographics
NPI:1821632985
Name:MUKISA, IAN JAMES (PA)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JAMES
Last Name:MUKISA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 EAST HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30909-5650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-787-1745
Practice Address - Street 1:DWIGHT DAVID EISENHOWER ARMY MEDICAL CENTER
Practice Address - Street 2:300 EAST HOSPITAL ROAD
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30909-5650
Practice Address - Country:US
Practice Address - Phone:631-568-1009
Practice Address - Fax:706-787-1745
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty