Healthcare Provider Details

I. General information

NPI: 1457334294
Provider Name (Legal Business Name): JOHN R BRIAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5495 S RAINBOW BLVD SUITE 201
LAS VEGAS NV
89118-1871
US

IV. Provider business mailing address

PO BOX 98813 SUITE 201
LAS VEGAS NV
89193-8813
US

V. Phone/Fax

Practice location:
  • Phone: 702-982-3659
  • Fax: 702-549-0377
Mailing address:
  • Phone: 702-982-3659
  • Fax: 702-549-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA692
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: