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General NPI Number Information
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NPI Number | 1871047639
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Entity Type | Individual
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Provider Name | ANDREW JEREMIAH DAVIDSON STUDENT
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Gender | Male
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Dates
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Enumeration Date | 08/10/2016
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 100 BREWSTER BLVD
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City | CAMP LEJEUNE
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State | NC
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Zip | 28547-2575
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Country | US
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Telephone | 214-668-9607
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Fax |
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Provider Business Mailing Address
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Address Line | 6232 MISSISSIPPI ST
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City | CAMP LEJEUNE
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State | NC
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Zip | 28547-2532
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Country | US
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Telephone | 214-668-9607
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 23588888
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1710I1002X
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Taxonomy Name | Independent Duty Corpsman
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License Number | 23588888
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License Number State | TX
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