Healthcare Provider Details

I. General information

NPI: 1093151227
Provider Name (Legal Business Name): DUSTIN V MECHAM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 N 4TH ST
LAS VEGAS NV
89101-1001
US

IV. Provider business mailing address

3704 THOMAS PATRICK AVE
NORTH LAS VEGAS NV
89032-8934
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-4044
  • Fax:
Mailing address:
  • Phone: 702-630-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number7877248-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN72654
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: