Healthcare Provider Details

I. General information

NPI: 1497218283
Provider Name (Legal Business Name): BRYAN MASARU OKAMURA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6171 W CHARLESTON BLVD BLDG 10
LAS VEGAS NV
89146-1126
US

IV. Provider business mailing address

10317 CANVAS CANYON CT
LAS VEGAS NV
89178-6541
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-7451
  • Fax:
Mailing address:
  • Phone: 702-614-6669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: