Healthcare Provider Details

I. General information

NPI: 1447510854
Provider Name (Legal Business Name): SISI TIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 S RAINBOW BLVD STE 250
LAS VEGAS NV
89118-1807
US

IV. Provider business mailing address

3016 W CHARLESTON BLVD STE 100
LAS VEGAS NV
89102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-6480
  • Fax: 702-671-6481
Mailing address:
  • Phone: 702-780-2315
  • Fax: 702-895-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number17068
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number17068
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA126477
License Number StateCA
# 4
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: