Healthcare Provider Details

I. General information

NPI: 1205813862
Provider Name (Legal Business Name): CHRISTOPHER DAVID DADIVAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2005
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5268
APO AP
96368-5268
US

IV. Provider business mailing address

PSC 80 BOX 12247
APO AP
96367-0025
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-5093
  • Fax:
Mailing address:
  • Phone: 801-888-7166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9596257-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: