MEDICARE: WADE ROBERT KERNAN 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	:	1639428667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WADE ROBERT KERNAN IDC

Provider Business Mailing Address
First Line	:	USS ABRAHAM LINCOLN
Second Line	:	CVN 72
City	:	FPO
State	:	AP
Zip	:	96612-2872
Country	:	US
Telephone Number	:	757-444-5199
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS ABRAHAM LINCOLN
Second Line	:	CVN 72
City	:	FPO
State	:	AP
Zip	:	96612-2872
Country	:	US
Telephone Number	:	757-444-5199
Fax Number	:

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

Provider Enumeration Date	:	09/06/2012
Last Update Date	:	09/07/2012

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