Healthcare Provider Details

I. General information

NPI: 1790384246
Provider Name (Legal Business Name): PAUL MARTIN T GUERRERO III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2020
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 DUNSHEE VISTA AVE
LAS VEGAS NV
89131-2026
US

IV. Provider business mailing address

5505 DUNSHEE VISTA AVE
LAS VEGAS NV
89131-2026
US

V. Phone/Fax

Practice location:
  • Phone: 702-768-3594
  • Fax:
Mailing address:
  • Phone: 702-768-3594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number819413
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: