Healthcare Provider Details

I. General information

NPI: 1104907559
Provider Name (Legal Business Name): JEREMY P KILBURN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-3257
  • Fax:
Mailing address:
  • Phone: 702-653-3257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01063719A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01063719A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number15402
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: