MEDICARE: JOHN PHOENIX APRN PLLC

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	363LF0000X	Family Nurse Practitioner	APRN001359	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134553068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN PHOENIX APRN PLLC

Provider Business Mailing Address
First Line	:	1909 COCHRAN ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-3538
Country	:	US
Telephone Number	:	702-523-9025
Fax Number	:	775-310-9190

Provider Business Practice Location Address
First Line	:	2000 S EASTERN AVE STE R
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-4100
Country	:	US
Telephone Number	:	702-523-9025
Fax Number	:	775-310-9190

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN R PHOENIX
Credential	:	APRN
Telephone Number	:	702-523-9025

Provider Enumeration Date	:	08/28/2013
Last Update Date	:	08/03/2024

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