MEDICARE: MR. IAN LARRY CHILDS PA-C

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	363A00000X	Physician Assistant	PA1233	NV

General Provider Information

NPI Number	:	1548572860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IAN LARRY CHILDS PA-C

Provider Business Mailing Address
First Line	:	1629 WINNERS CUP DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-0819
Country	:	US
Telephone Number	:	702-557-1045
Fax Number	:

Provider Business Practice Location Address
First Line	:	4785 S DURANGO DR
Second Line	:	STE. 101
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8166
Country	:	US
Telephone Number	:	702-889-8444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2010
Last Update Date	:	10/08/2014

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