Healthcare Provider Details

I. General information

NPI: 1336531417
Provider Name (Legal Business Name): JUAN E WANTIG AZCARRAGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUAN-ENRIQUE WANTIG

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8352 W WARM SPRINGS RD STE 210
LAS VEGAS NV
89113-3630
US

IV. Provider business mailing address

8352 W WARM SPRINGS RD STE 210
LAS VEGAS NV
89113-3630
US

V. Phone/Fax

Practice location:
  • Phone: 702-944-4028
  • Fax: 702-944-4019
Mailing address:
  • Phone: 702-944-4028
  • Fax: 702-944-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17337
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: