MEDICARE: MR. GARRY POBLETE CLOSAS CNS, ACNP

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	363LA2100X	Acute Care Nurse Practitioner	19530	CA

General Provider Information

NPI Number	:	1225389075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARRY POBLETE CLOSAS CNS, ACNP

Provider Business Mailing Address
First Line	:	USS CARL VINSON
Second Line	:	MEDICAL DEPARTMENT
City	:	FPO
State	:	AP
Zip	:	96629-2840
Country	:	US
Telephone Number	:	619-545-3616
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS CARL VINSON
Second Line	:	MEDICAL DEPARTMENT
City	:	FPO
State	:	AP
Zip	:	96629-2840
Country	:	US
Telephone Number	:	619-545-3616
Fax Number	:

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

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	09/19/2012

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