Healthcare Provider Details

I. General information

NPI: 1215190350
Provider Name (Legal Business Name): DOUGLAS EVERETT DILLON FPMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO, AP CA
96368
US

IV. Provider business mailing address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-3272
  • Fax: 719-556-7399
Mailing address:
  • Phone: 315-634-3272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number723752
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: