Healthcare Provider Details

I. General information

NPI: 1285366971
Provider Name (Legal Business Name): NATHAN SHANE GUILLERMO SO-IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRAVO 3 3D RECON BN UNIT 36180
FPO AP
96389-6180
US

IV. Provider business mailing address

BRAVO 3 3D RECON BN UNIT 36180
FPO AP
96389-6180
US

V. Phone/Fax

Practice location:
  • Phone: 915-539-5753
  • Fax:
Mailing address:
  • Phone: 915-539-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number07219916NG
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: