Healthcare Provider Details

I. General information

NPI: 1821355959
Provider Name (Legal Business Name): MATTHEW PETER JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 11/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W CHARLESTON BLVD
LAS VEGAS NV
89102
US

IV. Provider business mailing address

1800 W CHARLESTON BLVD
LAS VEGAS NV
89102
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-2000
  • Fax: 702-383-3620
Mailing address:
  • Phone: 702-383-2000
  • Fax: 702-383-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number16851
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: