MEDICARE: SUNRISE FOOT AND ANKLE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	0307	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508158536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE FOOT AND ANKLE LLC

Provider Business Mailing Address
First Line	:	4580 S EASTERN AVE STE 30
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6100
Country	:	US
Telephone Number	:	702-731-3338
Fax Number	:	702-731-3341

Provider Business Practice Location Address
First Line	:	4580 S EASTERN AVE STE 30
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6100
Country	:	US
Telephone Number	:	702-731-3338
Fax Number	:	702-731-3341

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. JEREMY WAYNE WOOD
Credential	:	DPM
Telephone Number	:	702-731-3338

Provider Enumeration Date	:	05/10/2011
Last Update Date	:	04/26/2012

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Directions to “SUNRISE FOOT AND ANKLE LLC ” Practice Location

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