Healthcare Provider Details

I. General information

NPI: 1336739911
Provider Name (Legal Business Name): COLTON JACK PERKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 02/14/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TINKER AFB
APO AP
73145
US

IV. Provider business mailing address

66849 LANDSTUHL, GERMANY
APO AE
01980
US

V. Phone/Fax

Practice location:
  • Phone: 405-986-3063
  • Fax:
Mailing address:
  • Phone: 210-996-9358
  • 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: