Provider Demographics
NPI:1952984254
Name:BADILLO, RYAN TYLER (SFIDC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TYLER
Last Name:BADILLO
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 1012 BOX 392
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34058-0004
Mailing Address - Country:US
Mailing Address - Phone:252-515-8641
Mailing Address - Fax:
Practice Address - Street 1:WHITE BLIGHT
Practice Address - Street 2:
Practice Address - City:ANDROS TOWN
Practice Address - State:ANDROS ISLAND
Practice Address - Zip Code:34058
Practice Address - Country:BS
Practice Address - Phone:252-515-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program