Healthcare Provider Details

I. General information

NPI: 1174460042
Provider Name (Legal Business Name): ANTONIO CARBAJAL II RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 41 BOX 1285
APO AE
09464-0013
US

IV. Provider business mailing address

PSC 41 BOX 1285
APO AE
09464-0013
US

V. Phone/Fax

Practice location:
  • Phone: 262-417-4688
  • Fax:
Mailing address:
  • Phone: 262-417-4688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number194024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: