1639171283 NPI number — EBERHARD JOHANNES MAENDEL PA-C

Table of content: EBERHARD JOHANNES MAENDEL PA-C (NPI 1639171283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639171283 NPI number — EBERHARD JOHANNES MAENDEL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAENDEL
Provider First Name:
EBERHARD
Provider Middle Name:
JOHANNES
Provider Name Prefix Text:
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:
1639171283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2285 CORPORATE CIR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89074-7759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-360-2763
Provider Business Mailing Address Fax Number:
949-783-2880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 S RANCHO DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89106-4873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-258-1001
Provider Business Practice Location Address Fax Number:
702-258-3455
Provider Enumeration Date:
08/12/2005

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:  569 , 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: P00436130 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: P00852334 . This is a "RR MEDICARE NV 10/2010" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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