Healthcare Provider Details

I. General information

NPI: 1649464975
Provider Name (Legal Business Name): ADVANCED ADOLESCENT PEDIATRIC GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8630 W CHEYENNE AVE
LAS VEGAS NV
89129-7260
US

IV. Provider business mailing address

PO BOX 36009
LAS VEGAS NV
89133-6009
US

V. Phone/Fax

Practice location:
  • Phone: 702-851-9383
  • Fax: 702-851-9380
Mailing address:
  • Phone: 702-851-9383
  • Fax: 702-851-9380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number11214
License Number StateNV

VIII. Authorized Official

Name: AJAZ A SHEIKH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 702-851-9383