Basic Information
| Provider Information | |||||||||
| NPI: | 1396125860 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DFAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233735 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233735 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2015 | ||||||||
| LastUpdateDate: | 05/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | PADGETT | ||||||||
| AuthorizedOfficialFirstName: | TYLER | ||||||||
| AuthorizedOfficialMiddleName: | BRADFORD | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5733010488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | Y | Hospitals | Military Hospital |
No ID Information.