Healthcare Provider Details

I. General information

NPI: 1295712693
Provider Name (Legal Business Name): FREMONT PRIMARY CARE - ENDOCRINOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 WYNN RD
LAS VEGAS NV
89103-5406
US

IV. Provider business mailing address

PO BOX 1737
LAS VEGAS NV
89125-1737
US

V. Phone/Fax

Practice location:
  • Phone: 702-362-3422
  • Fax: 702-939-8827
Mailing address:
  • Phone: 702-671-6800
  • Fax: 702-671-6855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JON GREG GRIFFIN
Title or Position: CEO
Credential:
Phone: 702-671-6800