Healthcare Provider Details

I. General information

NPI: 1003102823
Provider Name (Legal Business Name): LYLE MYTZLE A. MASANGKAY CRT, RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 WINTER WREN ST
LAS VEGAS NV
89122-3540
US

IV. Provider business mailing address

3611 WINTER WREN ST
LAS VEGAS NV
89122-3540
US

V. Phone/Fax

Practice location:
  • Phone: 702-461-1079
  • Fax:
Mailing address:
  • Phone: 702-461-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number121497
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: