Healthcare Provider Details

I. General information

NPI: 1407275464
Provider Name (Legal Business Name): JOSHUA HAYDUKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 S VALLEY VIEW BLVD
LAS VEGAS NV
89102-0116
US

IV. Provider business mailing address

4320 SAN JOAQUIN AVE
LAS VEGAS NV
89102-0614
US

V. Phone/Fax

Practice location:
  • Phone: 702-922-7015
  • Fax:
Mailing address:
  • Phone: 702-738-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: