Provider Demographics
NPI:1205558103
Name:FLETES, ANTHONY CHARLES (IDMT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:CHARLES
Last Name:FLETES
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19387A MONASTERY DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9269
Mailing Address - Country:US
Mailing Address - Phone:817-343-2441
Mailing Address - Fax:
Practice Address - Street 1:17455 AIRLIFTER DR
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3902
Practice Address - Country:US
Practice Address - Phone:907-551-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians