Healthcare Provider Details

I. General information

NPI: 1083378657
Provider Name (Legal Business Name): DENNIS FAJARDO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S CASINO CENTER BLVD
LAS VEGAS NV
89101-6102
US

IV. Provider business mailing address

6288 HUMUS AVE
LAS VEGAS NV
89139-5457
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5638
  • Fax:
Mailing address:
  • Phone: 702-639-7699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60732
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2469
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: