Healthcare Provider Details

I. General information

NPI: 1720603301
Provider Name (Legal Business Name): WILLIAM DONALD RN, EMT-P, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARCH AIR RESERVE BASE
MORENO VALLEY CA
92518
US

IV. Provider business mailing address

452ND ASTS MARCH AIR RESERVE BASE
APO AA
92518
US

V. Phone/Fax

Practice location:
  • Phone: 951-655-2751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP38530
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number80602094
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number744995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: