MEDICARE: WANDA GASTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1003386590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA GASTON

Provider Business Mailing Address
First Line	:	3925 N. MARTIN LUTHER KING BLVD STE 207
Second Line	:
City	:	NLV
State	:	NV
Zip	:	89032
Country	:	US
Telephone Number	:	702-684-7757
Fax Number	:	702-684-7381

Provider Business Practice Location Address
First Line	:	3925 N. MARTIN LUTHER KING BLVD STE 207
Second Line	:
City	:	NLV
State	:	NV
Zip	:	89032
Country	:	US
Telephone Number	:	702-684-7757
Fax Number	:	702-684-7381

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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Directions to “ WANDA GASTON ” Practice Location

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