Healthcare Provider Details

I. General information

NPI: 1073148201
Provider Name (Legal Business Name): NICHOLAS ROBERT BRULE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 W CHARLESTON BLVD
LAS VEGAS NV
89102-2254
US

IV. Provider business mailing address

1800 W CHARLESTON BLVD
LAS VEGAS NV
89102-2329
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-2663
  • Fax: 702-383-2682
Mailing address:
  • Phone: 702-383-2799
  • Fax: 702-383-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number29525
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: