Healthcare Provider Details

I. General information

NPI: 1609543313
Provider Name (Legal Business Name): JESSE CARLOS KIRTCHUK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
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: 702-653-2273
  • Fax:
Mailing address:
  • Phone: 702-653-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT030448
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: