=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285105940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. RYAN MICHAEL RODARTE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2018
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2665 S BRUCE ST APT 155
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89169-1757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-686-0852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5020 ALTA DR STE B
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-403-7999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364SH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | 2105320033
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------