MEDICARE: NICHOLAS SANDERSON IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1033596721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS SANDERSON IDC

Provider Business Mailing Address
First Line	:	USS OLYMPIA (SSN-717)
Second Line	:	COMMANDING OFFICER
City	:	FPO
State	:	AP
Zip	:	96674-2397
Country	:	US
Telephone Number	:	808-590-7884
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS OLYMPIA (SSN-717)
Second Line	:	COMMANDING OFFICER
City	:	FPO
State	:	AP
Zip	:	96674-2397
Country	:	US
Telephone Number	:	808-590-7884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2015
Last Update Date	:	05/01/2015

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