Healthcare Provider Details

I. General information

NPI: 1972129476
Provider Name (Legal Business Name): MICHAEL DEVIN DOUGHERTY ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100 BOX LANDSTUHL
APO AE
09180-3100
US

IV. Provider business mailing address

UNIT 33100 BOX LANDSTUHL
APO AE
09180-3100
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-5056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11007658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: