MEDICARE: JACQUELYN VILLAGOMEZ DANESHFOROUZ PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1649728775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN VILLAGOMEZ DANESHFOROUZ PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	2863 SAINT ROSE PKWY
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-4806
Country	:	US
Telephone Number	:	702-483-4483
Fax Number	:	702-493-0357

Provider Business Practice Location Address
First Line	:	8530 W SUNSET RD STE 230
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113
Country	:	US
Telephone Number	:	702-483-4483
Fax Number	:	702-483-4493

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

Provider Enumeration Date	:	09/19/2016
Last Update Date	:	01/22/2026

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