Provider Demographics
NPI:1891853743
Name:D CO 168TH MED BN BOX 36B APO AP 96218
Entity Type:Organization
Organization Name:D CO 168TH MED BN BOX 36B APO AP 96218
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEJUANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RIAT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:134-737-5272
Mailing Address - Street 1:D CO 168TH MED BN UNIT 15021
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96218
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:D CO 168TH MED BN UNIT 15021 BOX 36B
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96218
Practice Address - Country:KR
Practice Address - Phone:314-764-5272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component