Healthcare Provider Details

I. General information

NPI: 1164555736
Provider Name (Legal Business Name): UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 FIRE MESA ST STE 180
LAS VEGAS NV
89128-9016
US

IV. Provider business mailing address

PO BOX 98528 DEPT 401
LAS VEGAS NV
89193-8528
US

V. Phone/Fax

Practice location:
  • Phone: 702-992-6888
  • Fax: 702-992-6880
Mailing address:
  • Phone: 702-671-2395
  • Fax: 702-382-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. WILLIAM A. ZAMBONI
Title or Position: VICE DEAN
Credential: MD
Phone: 702-671-2278