Basic Information
Provider Information
NPI: 1003140344
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COUCH
FirstName: CHRISTOPHER
MiddleName: SHAWN
NamePrefix:  
NameSuffix:  
Credential: IDMT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 718 I AVE 82 MSS/DPF
Address2: BLDG 1900 DEPT XUFB
City: SHEPPARD AFB
State: TX
PostalCode: 76311
CountryCode: US
TelephoneNumber: 9406763818
FaxNumber:  
Practice Location
Address1: 718 I AVE 82 MSS/DPF
Address2: BLDG 1900 DEPT XUFB
City: SHEPPARD AFB
State: TX
PostalCode: 76311
CountryCode: US
TelephoneNumber: 9406763818
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/18/2009
LastUpdateDate: 09/18/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1710I1003X  Y Other Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians

No ID Information.


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