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General NPI Number Information
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NPI Number | 1609268697
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Entity Type | Individual
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Provider Name | PA DER CHA
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Gender | Female
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Dates
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Enumeration Date | 02/27/2015
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Last Update Date | 08/10/2015
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Provider Practice Location Address
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Address Line | 3850 LAS VEGAS BLVD S
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City | LAS VEGAS
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State | NV
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Zip | 89109-4324
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Country | US
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Telephone | 952-222-2222
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Fax |
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Provider Business Mailing Address
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Address Line | 3850 LAS VEGAS BLVD S
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City | LAS VEGAS
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State | NV
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Zip | 89109-4324
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Country | US
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Telephone | 952-222-2222
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP0504X
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Taxonomy Name | Public Medicine Podiatrist
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License Number | 123456
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License Number State | NV
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