1699802926 NPI number — MR. BASEL AL-ADHAM PA-C

Table of content: MR. CHRISTOPHER CHARLES OBST LPC (NPI 1598588733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699802926 NPI number — MR. BASEL AL-ADHAM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AL-ADHAM
Provider First Name:
BASEL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1699802926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3090 VIALE MARCO POLO
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:
89052-4131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-614-6550
Provider Business Mailing Address Fax Number:
702-614-6562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3006 S MARYLAND PKWY
Provider Second Line Business Practice Location Address:
SUITE 690
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89109-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-732-1290
Provider Business Practice Location Address Fax Number:
702-732-1385
Provider Enumeration Date:
02/27/2007

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:  PA2020-0008 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: 421 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: VWCLCQ . This is a "MEDICARE GROUP" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 2402308 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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