Healthcare Provider Details

I. General information

NPI: 1184867301
Provider Name (Legal Business Name): ROBERT GREGORY NYDAM IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S RANCHO DR
LAS VEGAS NV
89106-3810
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-8600
  • Fax: 702-258-6152
Mailing address:
  • Phone: 702-877-8600
  • Fax: 702-258-6152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: