Healthcare Provider Details

I. General information

NPI: 1821569138
Provider Name (Legal Business Name): FIFE DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 W. HORIZON RIDGE PARKWAY
HENDERSON NV
89012
US

IV. Provider business mailing address

6460 MEDICAL CENTER STREET STE 350
LAS VEGAS NV
89148-2423
US

V. Phone/Fax

Practice location:
  • Phone: 702-255-6647
  • Fax: 702-933-1444
Mailing address:
  • Phone: 702-255-6647
  • Fax: 702-933-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANA I LEE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 702-798-3008