Provider Demographics
NPI:1851668834
Name:DEPARTMENT OF DEFENSE
Entity Type:Organization
Organization Name:DEPARTMENT OF DEFENSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAPTAIN/PHYSICIAN'S ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:706-787-1102
Mailing Address - Street 1:41ST STREET
Mailing Address - Street 2:BLDG 40709 ROOM 207 DDEAMC; MEB, PAD
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:706-787-1102
Mailing Address - Fax:
Practice Address - Street 1:41ST STREET
Practice Address - Street 2:BLDG 40709 ROOM 207 DDEAMC; MEB, PAD
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02514363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty