Healthcare Provider Details

I. General information

NPI: 1578263984
Provider Name (Legal Business Name): ANDREW ATOA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date: 03/21/2025
Reactivation Date: 04/03/2025

III. Provider practice location address

9300 W SUNSET RD
LAS VEGAS NV
89148-4844
US

IV. Provider business mailing address

420 E BEAUMONT RD
COLUMBUS OH
43214-2202
US

V. Phone/Fax

Practice location:
  • Phone: 702-916-5000
  • Fax:
Mailing address:
  • Phone: 801-473-0252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number42048234
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: