Provider Demographics
NPI:1720458599
Name:MERRILL, RICHARD MARK (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:MERRILL
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:MARK
Other - Last Name:MERRILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPNP - AC/PC
Mailing Address - Street 1:PSC 50 BOX 563
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09494-0006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:422 MDS/SGN
Practice Address - Street 2:UNIT 4628
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09494-4628
Practice Address - Country:US
Practice Address - Phone:314-236-8125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9361765-4405363LP0222X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care