Healthcare Provider Details

I. General information

NPI: 1346154382
Provider Name (Legal Business Name): EZRA VAUGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 26012, CAROLINES AVENUE ANDERSEN AFB
YIGO GU
96929
US

IV. Provider business mailing address

BUILDING 26012, CAROLINES AVENUE ANDERSEN AFB
YIGO GU
96929
US

V. Phone/Fax

Practice location:
  • Phone: 671-366-2772
  • Fax:
Mailing address:
  • Phone: 671-366-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: