Provider Demographics
NPI:1366773038
Name:FARIA, MARIO M
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:M
Last Name:FARIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 THRESHER AVE
Mailing Address - Street 2:USS PENNSYLVANIA SSBN 735
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 THRESHER AVE
Practice Address - Street 2:USS PENNSYLVANIA SSBN 735
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98315
Practice Address - Country:US
Practice Address - Phone:360-476-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman