Healthcare Provider Details

I. General information

NPI: 1083783336
Provider Name (Legal Business Name): RONALD MEREL HUSMAN SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS FORD FFG 54 ATTN MEDICAL DEPARTMENT
FPO AP WA
96665-1508
US

IV. Provider business mailing address

10705 130TH AVE NE
LAKE STEVENS WA
98258-8878
US

V. Phone/Fax

Practice location:
  • Phone: 425-304-5204
  • Fax: 425-304-5202
Mailing address:
  • Phone: 360-657-5473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: