MEDICARE: KORNELIS POELSTRA M.D.

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	207XS0117X	Orthopaedic Surgery of the Spine Physician	20020	NV

General Provider Information

NPI Number	:	1467496828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KORNELIS POELSTRA M.D.

Provider Business Mailing Address
First Line	:	7140 SMOKE RANCH RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-3157
Country	:	US
Telephone Number	:	702-320-8111
Fax Number	:	702-320-8112

Provider Business Practice Location Address
First Line	:	7140 SMOKE RANCH RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-3157
Country	:	US
Telephone Number	:	702-320-8111
Fax Number	:	702-320-8112

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	03/12/2025

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