Healthcare Provider Details

I. General information

NPI: 1497757181
Provider Name (Legal Business Name): TODD A RADIVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S RANCHO DR
LAS VEGAS NV
89106-3810
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-8600
  • Fax:
Mailing address:
  • Phone: 702-877-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2007
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2007
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: