Healthcare Provider Details

I. General information

NPI: 1093242521
Provider Name (Legal Business Name): ANDRE PROCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3081 S VALLEY VIEW BLVD
LAS VEGAS NV
89102-7890
US

IV. Provider business mailing address

2051 N TORREY PINES DR APT 2096
LAS VEGAS NV
89108-6528
US

V. Phone/Fax

Practice location:
  • Phone: 702-910-3230
  • Fax: 702-910-3230
Mailing address:
  • Phone: 702-480-7416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: