MEDICARE: NEVADA ESCAPA

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	174400000X	Specialist		NV

General Provider Information

NPI Number	:	1164382503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEVADA ESCAPA

Provider Business Mailing Address
First Line	:	6535 N TIOGA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-3539
Country	:	US
Telephone Number	:	702-289-9052
Fax Number	:

Provider Business Practice Location Address
First Line	:	6535 N TIOGA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-3539
Country	:	US
Telephone Number	:	702-289-9052
Fax Number	:

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

Provider Enumeration Date	:	11/17/2025
Last Update Date	:	11/17/2025

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Directions to “ NEVADA ESCAPA ” Practice Location

Language	Start Address	Practice Location

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