Healthcare Provider Details

I. General information

NPI: 1992327712
Provider Name (Legal Business Name): MAHMOUD R MOGHADAM FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 01/11/2024
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 WAYNE NEWTON
LAS VEGAS NV
89111
US

IV. Provider business mailing address

1800 W CHARLESTON BLVD
LAS VEGAS NV
89102
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-2527
  • Fax: 702-383-1991
Mailing address:
  • Phone: 702-765-7920
  • Fax: 702-383-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number823272
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number823272
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: