Healthcare Provider Details

I. General information

NPI: 1487816633
Provider Name (Legal Business Name): MR. DEONTAE ANTHONY KARRON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ANDREWS AVE BOX 42
FORT RUCKER AL
36362
US

IV. Provider business mailing address

301 ANDREWS AVE BOX42
FORT RUCKER AL
36362
US

V. Phone/Fax

Practice location:
  • Phone: 334-447-3711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: