Healthcare Provider Details

I. General information

NPI: 1740870070
Provider Name (Legal Business Name): ELISEO DE VEYRA MERCADO III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 S EASTERN AVE STE 101
HENDERSON NV
89052-3908
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 702-616-5801
  • Fax:
Mailing address:
  • Phone: 24-064-7866
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number833724
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number833724
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: