Healthcare Provider Details

I. General information

NPI: 1740733849
Provider Name (Legal Business Name): REVOLUTION EMERGENCY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 E LOHMAN AVE
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

PO BOX 99021
LAS VEGAS NV
89193-9021
US

V. Phone/Fax

Practice location:
  • Phone: 469-401-2386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY J BYRNE
Title or Position: OFFICER
Credential:
Phone: 469-401-2386