MEDICARE: UNITED STATES AIR FORCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	286500000X	Military Hospital

General Provider Information

NPI Number	:	1891930244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED STATES AIR FORCE

Provider Business Mailing Address
First Line	:	6501 VEGAS DR APT 1034
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-7773
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6501 VEGAS DR APT 1034
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-7773
Country	:	US
Telephone Number	:	318-347-4651
Fax Number	:

Authorized Official
Title or Position	:	PA STUDENT
Name	:	JASON ROBERT CROCKETT
Credential	:
Telephone Number	:	318-347-4651

Provider Enumeration Date	:	12/12/2008
Last Update Date	:	12/12/2008

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Directions to “UNITED STATES AIR FORCE ” Practice Location

Language	Start Address	Practice Location

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