MEDICARE: AMBER BLANCO

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer		NV

General Provider Information

NPI Number	:	1447880042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER BLANCO

Provider Business Mailing Address
First Line	:	4535 EL CAMPANA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6506
Country	:	US
Telephone Number	:	702-541-0118
Fax Number	:

Provider Business Practice Location Address
First Line	:	4535 EL CAMPANA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6506
Country	:	US
Telephone Number	:	702-541-0118
Fax Number	:

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

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/22/2020

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Directions to “ AMBER BLANCO ” Practice Location

Language	Start Address	Practice Location

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