Basic Information
Provider Information | |||||||||
NPI: | 1437523388 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DFAS ATTN:DFASIN/JAMBF | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
Address2: | 9040 REID STREET, ATTN: MCHJ-CLQ-C | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984311100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539682252 | ||||||||
FaxNumber: | 2539683278 | ||||||||
Practice Location | |||||||||
Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
Address2: | 9040 REID STREET, ATTN: MCHJ-CLQ-C | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984311100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539682252 | ||||||||
FaxNumber: | 2539683278 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2015 | ||||||||
LastUpdateDate: | 12/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIESEMER | ||||||||
AuthorizedOfficialFirstName: | KIRK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BDE SURGEON | ||||||||
AuthorizedOfficialTelephone: | 2534772284 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.