MEDICARE: JONATHON DAVID POWELL

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	:	1346785136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHON DAVID POWELL

Provider Business Mailing Address
First Line	:	18524 140TH AVE
Second Line	:
City	:	SPRINGFIELD GARDENS
State	:	NY
Zip	:	11413-2614
Country	:	US
Telephone Number	:	858-666-5232
Fax Number	:

Provider Business Practice Location Address
First Line	:	18524 140TH AVE
Second Line	:
City	:	SPRINGFIELD GARDENS
State	:	NY
Zip	:	11413-2614
Country	:	US
Telephone Number	:	860-694-2876
Fax Number	:

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

Provider Enumeration Date	:	01/03/2017
Last Update Date	:	01/03/2017

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