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General NPI Number Information
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NPI Number | 1851668834
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF DEFENSE
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Dates
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Enumeration Date | 11/19/2011
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Last Update Date | 11/19/2011
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Provider Practice Location Address
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Address Line | 41ST STREET BLDG 40709 ROOM 207 DDEAMC; MEB, PAD
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City | FORT GORDON
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State | GA
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Zip | 30905
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Country | US
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Telephone | 706-787-1102
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Fax |
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Provider Business Mailing Address
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Address Line | 41ST STREET BLDG 40709 ROOM 207 DDEAMC; MEB, PAD
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City | FORT GORDON
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State | GA
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Zip | 30905
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Country | US
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Telephone | 706-787-1102
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Fax |
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Authorized Official
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Title or Position | CAPTAIN/PHYSICIAN'S ASSISTANT
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Name | HECTOR LUIS LUNA
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Credential | PA-C
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Telephone | 706-787-1102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0010-02514
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License Number State | NC
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