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General NPI Number Information
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NPI Number | 1821896804
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE DERMATOLOGY PA CLINIC
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 03/07/2025
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Provider Practice Location Address
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Address Line | 1110 ECHO PASS ST.
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City | HENDERSON
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State | NV
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Zip | 89052
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Country | US
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Telephone | 941-840-1387
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Fax |
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Provider Business Mailing Address
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Address Line | 7533 S CENTER VIEW CT STE R
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City | WEST JORDAN
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State | UT
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Zip | 84084-5526
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Country | US
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Telephone | 941-840-1387
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSOCIATE
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Name | FEROZA THOMPSON
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Credential | PA-C
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Telephone | 941-840-1387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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