=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679379572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EON WELLNESS AND PRIMARY CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2025
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2650 SPRINGSTONE ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89142-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-509-7376
-----------------------------------------------------
Fax | 702-509-7371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2650 SPRINGSTONE ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89142-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-509-7376
-----------------------------------------------------
Fax | 702-509-7371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | JUSTIN PEDRAZA
-----------------------------------------------------
Credential | MSN, APRN, FNP-BC
-----------------------------------------------------
Telephone | 702-629-0245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------