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NPI Code Detail

MEDICARE: EDGAR EVANGELISTA MD PC

MEDICARE: EDGAR EVANGELISTA MD PC
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
12084D0003XDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
22084N0400XNeurology Physician
3363L00000XNurse Practitioner
42084N0600XClinical Neurophysiology Physician

General Provider Information

NPI Number : 1396028619
Entity Type Code : Organization
Provider Name (Legal Business Name) : EDGAR EVANGELISTA MD PC
Provider Business Mailing Address
First Line : 1452 W HORIZON RIDGE PKWY # 566
Second Line :
City : HENDERSON
State : NV
Zip : 89012-4422
Country : US
Telephone Number : 702-800-7831
Fax Number : 877-409-2014
Provider Business Practice Location Address
First Line : 2110 E FLAMINGO RD STE 201
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-5192
Country : US
Telephone Number : 702-800-7831
Fax Number : 877-409-2014
Authorized Official
Title or Position : PRESIDENT
Name : EDGAR JAY B EVANGELISTA
Credential : MD
Telephone Number : 702-800-7831
Provider Enumeration Date : 09/22/2011
Last Update Date : 05/22/2024

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