Healthcare Provider Details

I. General information

NPI: 1437230919
Provider Name (Legal Business Name): DOUGLAS W AVILLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CAISSON HILL ROAD ATTN:MCXX-CLD-QM (CREDENETIALS)
FORT RILEY KS
66442-5037
US

IV. Provider business mailing address

600 CAISSON HILL ROAD ATTN:MCXX-CLD-QM (CREDENETIALS)
FORT RILEY KS
66442-5037
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-5181
  • Fax: 785-239-7364
Mailing address:
  • Phone: 785-239-5181
  • Fax: 785-239-7364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: