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General NPI Number Information
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NPI Number | 1184850760
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Entity Type | Individual
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Provider Name | JOSE VICTOR NAZARIO IDMT
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Gender | Male
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Dates
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Enumeration Date | 06/09/2009
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 325 MDG 340 MAGNOLIA CIRCLE
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City | TYNDALL AFB
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State | FL
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Zip | 32403-8888
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Country | US
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Telephone | 240-216-3247
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Fax |
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Provider Business Mailing Address
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Address Line | 628 ED MOYE RD
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City | LA GRANGE
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State | NC
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Zip | 28551-8888
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Country | US
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Telephone | 240-216-3247
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1710I1003X
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Taxonomy Name | Independent Duty Medical Technicians
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License Number |
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License Number State |
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