Healthcare Provider Details

I. General information

NPI: 1831420900
Provider Name (Legal Business Name): MARY ANNE Q EISMA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 10/06/2017
Certification Date:
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
89191-6601
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-2766
  • Fax:
Mailing address:
  • Phone: 702-653-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number02003990A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: