Healthcare Provider Details

I. General information

NPI: 1528828282
Provider Name (Legal Business Name): PENGFENG JACK JIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 S FORT APACHE RD
LAS VEGAS NV
89148-7700
US

IV. Provider business mailing address

6630 ARROYO SPRINGS ST STE 1200
LAS VEGAS NV
89113-1948
US

V. Phone/Fax

Practice location:
  • Phone: 702-900-9888
  • Fax: 888-316-6618
Mailing address:
  • Phone: 702-900-9888
  • Fax: 888-316-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number27917
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberLL4184
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: