1669039798 NPI number — COY DYLAN PARKER INDEPENDENT DUTY COR

Table of content: COY DYLAN PARKER INDEPENDENT DUTY COR (NPI 1669039798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669039798 NPI number — COY DYLAN PARKER INDEPENDENT DUTY COR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARKER
Provider First Name:
COY
Provider Middle Name:
DYLAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
INDEPENDENT DUTY COR
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:
1669039798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11439 MADERA ROSA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-295-8153
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SURFACE WARFARE MEDICAL INSTITUTE
Provider Second Line Business Practice Location Address:
34101 FARENHOLT AVE
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-532-6659
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2019

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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