Provider Demographics
NPI:1285366971
Name:GUILLERMO, NATHAN SHANE (SO-IDC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:SHANE
Last Name:GUILLERMO
Suffix:
Gender:M
Credentials:SO-IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRAVO 3 3D RECON BN
Mailing Address - Street 2:UNIT 36180
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96389-6180
Mailing Address - Country:US
Mailing Address - Phone:915-539-5753
Mailing Address - Fax:
Practice Address - Street 1:BRAVO 3 3D RECON BN
Practice Address - Street 2:UNIT 36180
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96389-6180
Practice Address - Country:US
Practice Address - Phone:915-539-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
07219916NG1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman