Basic Information
| Provider Information | |||||||||
| NPI: | 1821632985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUKISA | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 EAST HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309095650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7067871745 | ||||||||
| Practice Location | |||||||||
| Address1: | DWIGHT DAVID EISENHOWER ARMY MEDICAL CENTER | ||||||||
| Address2: | 300 EAST HOSPITAL ROAD | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309095650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315681009 | ||||||||
| FaxNumber: | 7067871745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.