1609389097 NPI number — JOHN CHARLES BOCKMANN PHYSICIAN ASSISTANT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609389097 NPI number — JOHN CHARLES BOCKMANN PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOCKMANN
Provider First Name:
JOHN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
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:
1609389097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11766A ORCHARD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DRUM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13603-3126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-974-2093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CONNOR TROOP MEDICAL CLINIC
Provider Second Line Business Practice Location Address:
10506 EUPHRATES RIVER VALLEY RD
Provider Business Practice Location Address City Name:
FORT DRUM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-974-2093
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2017

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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