Healthcare Provider Details

I. General information

NPI: 1851145171
Provider Name (Legal Business Name): MARK DAVID FAJARDO APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 W CHEYENNE AVE
NORTH LAS VEGAS NV
89032-2484
US

IV. Provider business mailing address

4310 W CHEYENNE AVE
NORTH LAS VEGAS NV
89032-2484
US

V. Phone/Fax

Practice location:
  • Phone: 702-763-7811
  • Fax:
Mailing address:
  • Phone: 702-763-7811
  • Fax: 702-947-4920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number817938
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: