1417949314 NPI number — TIMOTHY PHAN CRNA

Table of content: TIMOTHY PHAN CRNA (NPI 1417949314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417949314 NPI number — TIMOTHY PHAN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAN
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1417949314
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7385 S PECOS RD
Provider Second Line Business Mailing Address:
STE 103
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89120-3768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-221-2297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 S LOLA LN
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PAHRUMP
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89048-0878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-751-7500
Provider Business Practice Location Address Fax Number:
775-751-7824
Provider Enumeration Date:
08/17/2005

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: 367500000X , with the licence number:  CRNA000265 , 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: 100505726 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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