Healthcare Provider Details

I. General information

NPI: 1164599478
Provider Name (Legal Business Name): SIERRA NEUROLOGY LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

896 W NYE LN SUITE 203
CARSON CITY NV
89703-1544
US

IV. Provider business mailing address

896 W NYE LN SUITE 203
CARSON CITY NV
89703-1544
US

V. Phone/Fax

Practice location:
  • Phone: 775-883-4411
  • Fax: 775-883-1701
Mailing address:
  • Phone: 775-883-4411
  • Fax: 775-883-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number1253
License Number StateNV

VIII. Authorized Official

Name: MIRACLE WANGSUWANA
Title or Position: PARTNER
Credential: D.O.
Phone: 775-883-4411