Healthcare Provider Details

I. General information

NPI: 1275746281
Provider Name (Legal Business Name): PETER ANDREW JANSE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 455 BOX 191
FPO AP
96540-9998
US

IV. Provider business mailing address

16 HUTCHINS ST
SANTA RITA GU
96915-1119
US

V. Phone/Fax

Practice location:
  • Phone: 671-333-4202
  • Fax:
Mailing address:
  • Phone: 671-333-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: