Healthcare Provider Details

I. General information

NPI: 1689422941
Provider Name (Legal Business Name): RAVEN ANGELIQUE JABAR UY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7380 W SAHARA AVE STE 160
LAS VEGAS NV
89117-2762
US

IV. Provider business mailing address

7380 W SAHARA AVE STE 160
LAS VEGAS NV
89117-2762
US

V. Phone/Fax

Practice location:
  • Phone: 702-779-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA3392
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: