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General NPI Number Information
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NPI Number | 1366802159
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Entity Type | Organization
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Legal Business Name | GOOD SAMARITAN FAMILY PRACTICE
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Dates
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Enumeration Date | 03/07/2016
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Last Update Date | 03/07/2016
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Provider Practice Location Address
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Address Line | 4220 SAXTON GREEN AVENUE
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City | LAS VEGAS
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State | NV
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Zip | 89141
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Country | US
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Telephone | 702-400-0517
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Fax |
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Provider Business Mailing Address
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Address Line | 4220 SAXTON GREEN AVE
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City | LAS VEGAS
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State | NV
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Zip | 89141-4354
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Country | US
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Telephone | 702-400-0517
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTICTIONER
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Name | STANLEY M KIDIAVAYI
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Credential | APRN
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Telephone | 702-400-0517
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN002072
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License Number State | NV
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