Provider Demographics
NPI:1801929237
Name:BREBONERIA, JUAN NIOSCO JR (IDC)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:NIOSCO
Last Name:BREBONERIA
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS MCCAMPBELL
Mailing Address - Street 2:DDG 85
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96672-1275
Mailing Address - Country:US
Mailing Address - Phone:0118146-816-2260
Mailing Address - Fax:
Practice Address - Street 1:USS MCCAMPBELL
Practice Address - Street 2:DDG 85
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96672-1275
Practice Address - Country:US
Practice Address - Phone:0118146-816-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman