Healthcare Provider Details

I. General information

NPI: 1487746459
Provider Name (Legal Business Name): BRIAN EDWARD GRACE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5188 BLISSFUL VALLEY CIR
LAS VEGAS NV
89149-5262
US

IV. Provider business mailing address

5188 BLISSFUL VALLEY CIR
LAS VEGAS NV
89149-5262
US

V. Phone/Fax

Practice location:
  • Phone: 702-373-9929
  • Fax: 800-886-2862
Mailing address:
  • Phone: 702-373-9929
  • Fax: 800-886-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA727
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: