MEDICARE: KENNETH TAM NP-C

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	363LF0000X	Family Nurse Practitioner	AP118688	TX

General Provider Information

NPI Number	:	1477884138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH TAM NP-C

Provider Business Mailing Address
First Line	:	9048 HERRING COVE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-6269
Country	:	US
Telephone Number	:	512-743-1829
Fax Number	:	512-590-7104

Provider Business Practice Location Address
First Line	:	4141 SWENSON ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6718
Country	:	US
Telephone Number	:	702-733-0320
Fax Number	:

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

Provider Enumeration Date	:	01/20/2010
Last Update Date	:	03/02/2019

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