MEDICARE: MARY MANOHARAN

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	363LA2200X	Adult Health Nurse Practitioner	APRN001221	NV

General Provider Information

NPI Number	:	1275037517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MANOHARAN

Provider Business Mailing Address
First Line	:	8552 WINDSOR RUN ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6820
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 N MLK BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2825
Country	:	US
Telephone Number	:	702-967-0530
Fax Number	:

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

Provider Enumeration Date	:	03/21/2018
Last Update Date	:	03/21/2018

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