1649276254 NPI number — CAROLYN A. DECHAINE PA - C

Table of content: CAROLYN A. DECHAINE PA - C (NPI 1649276254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649276254 NPI number — CAROLYN A. DECHAINE PA - C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECHAINE
Provider First Name:
CAROLYN
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA - C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649276254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2370 CORPORATE CIR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89074-7760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-910-3950
Provider Business Mailing Address Fax Number:
702-778-2264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
653 N TOWN CENTER DR STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-844-4842
Provider Business Practice Location Address Fax Number:
702-284-4484
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA776 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1649276254 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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