Healthcare Provider Details

I. General information

NPI: 1255801049
Provider Name (Legal Business Name): JOSE EDWIN AVILES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
ELMENDORF AFB AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE
ELMENDORF AFB AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 509-715-8291
  • Fax:
Mailing address:
  • Phone: 509-715-8291
  • 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: