Healthcare Provider Details

I. General information

NPI: 1316535487
Provider Name (Legal Business Name): SAMUEL WADE CUIDON IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE # 3349
EIELSON AFB AK
99702-2301
US

IV. Provider business mailing address

2630 CENTRAL AVE # 3349
EIELSON AFB AK
99702-2301
US

V. Phone/Fax

Practice location:
  • Phone: 405-582-6048
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: