Healthcare Provider Details

I. General information

NPI: 1669608881
Provider Name (Legal Business Name): JEREMY DON ASTIN IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEREMY DON ASTIN IDMT

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR
FE WARREN AFB WY
82005-3906
US

IV. Provider business mailing address

6900 ALDEN DR
FE WARREN AFB WY
82005-3906
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-4212
  • Fax:
Mailing address:
  • Phone: 307-773-4212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: