1427158203 NPI number — MIKEL M MERRITT PHD

Table of content: LILLIAN JANET TRYON FNP-BC (NPI 1730526252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427158203 NPI number — MIKEL M MERRITT PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERRITT
Provider First Name:
MIKEL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427158203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2729 SOCORRO LOOP APT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLOMAN AFB
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88330-7124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-572-5676
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
359 MDG
Provider Second Line Business Practice Location Address:
221 3RD ST W
Provider Business Practice Location Address City Name:
RANDOLPH AFB
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-652-2448
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  682 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)