Provider Demographics
NPI:1801134697
Name:UNITED STATES AIR FORCE
Entity type:Organization
Organization Name:UNITED STATES AIR FORCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:AGUIAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:314-884-2191
Mailing Address - Street 1:UNIT 5142
Mailing Address - Street 2:18 MEDICAL GROUP, BLDG 626
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96368-5142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 MEDICAL GROUP
Practice Address - Street 2:BLDG 626
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368
Practice Address - Country:US
Practice Address - Phone:314-884-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX667240261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care