Healthcare Provider Details

I. General information

NPI: 1770017394
Provider Name (Legal Business Name): ROBERT KENNETH EWING II D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 SIERRA ROSE DR. SUITE 103
RENO NV
89509
US

IV. Provider business mailing address

645 SIERRA ROSE DR STE 103
RENO NV
89511-4025
US

V. Phone/Fax

Practice location:
  • Phone: 775-322-3011
  • Fax: 775-322-1849
Mailing address:
  • Phone: 775-322-3011
  • Fax: 775-322-1849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number449
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: