Healthcare Provider Details

I. General information

NPI: 1790987113
Provider Name (Legal Business Name): DUANE WYLAND OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S VALLEY VIEW BLVD
LAS VEGAS NV
89102-1855
US

IV. Provider business mailing address

1250 S VALLEY VIEW BLVD
LAS VEGAS NV
89102-1855
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-8898
  • Fax:
Mailing address:
  • Phone: 555-123-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number09-0197
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: