MEDICARE: LUKE V. DESJARLAIS, 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	363AS0400X	Surgical Physician Assistant	PA1333	NV

General Provider Information

NPI Number	:	1184977555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUKE V. DESJARLAIS, PLLC

Provider Business Mailing Address
First Line	:	9035 WESTCHESTER HILL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-4926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9035 WESTCHESTER HILL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-4926
Country	:	US
Telephone Number	:	702-415-3463
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LUKE V DESJARLAIS
Credential	:	PAC
Telephone Number	:	702-415-3463

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	10/22/2012

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