Healthcare Provider Details

I. General information

NPI: 1770377145
Provider Name (Legal Business Name): CHAIWAT CHULSUWAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 S DURANGO DR
LAS VEGAS NV
89113-0173
US

IV. Provider business mailing address

820 QUICKSAND LN
NORTH LAS VEGAS NV
89032-7615
US

V. Phone/Fax

Practice location:
  • Phone: 702-463-5556
  • Fax:
Mailing address:
  • Phone: 702-576-8677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number874599
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number874599
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: