Healthcare Provider Details

I. General information

NPI: 1598027237
Provider Name (Legal Business Name): EPAFARA JEFFREY VAITAUTOLU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WENCKER WAY APT A
BREMERTON WA
98312-1861
US

IV. Provider business mailing address

USS NIMITZ CVN -68
FPO AP
96620-2820
US

V. Phone/Fax

Practice location:
  • Phone: 360-434-1434
  • Fax:
Mailing address:
  • Phone: 360-434-1434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: