Healthcare Provider Details

I. General information

NPI: 1669660221
Provider Name (Legal Business Name): QUANETTA LINDA BAZILE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3186 S MARYLAND PKWY
LAS VEGAS NV
89109-2317
US

IV. Provider business mailing address

3186 S MARYLAND PKWY
LAS VEGAS NV
89109-2317
US

V. Phone/Fax

Practice location:
  • Phone: 702-961-7310
  • Fax: 844-231-4920
Mailing address:
  • Phone: 702-961-7310
  • Fax: 844-231-4920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05764
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004715
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1703
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: