Healthcare Provider Details

I. General information

NPI: 1912182890
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY PROF ASSN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3196 S MARYLAND PKWY STE 309
LAS VEGAS NV
89109-2314
US

IV. Provider business mailing address

3196 S MARYLAND PKWY STE 309
LAS VEGAS NV
89109-2314
US

V. Phone/Fax

Practice location:
  • Phone: 702-791-0477
  • Fax: 702-791-6831
Mailing address:
  • Phone: 702-791-0477
  • Fax: 702-791-6831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number6739
License Number StateNV

VIII. Authorized Official

Name: DR. HOWARD I BARON
Title or Position: OWNER
Credential: M.D.
Phone: 702-791-0477