MEDICARE: RENATO OLEDAN RABARA FNP-C LLC

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

General Provider Information

NPI Number	:	1659885184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENATO OLEDAN RABARA FNP-C LLC

Provider Business Mailing Address
First Line	:	9958 CORBRIDGE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-3821
Country	:	US
Telephone Number	:	702-677-0661
Fax Number	:	702-854-9780

Provider Business Practice Location Address
First Line	:	9958 CORBRIDGE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-3821
Country	:	US
Telephone Number	:	702-677-0661
Fax Number	:	702-854-9780

Authorized Official
Title or Position	:	OWNER
Name	:	RENATO OLEDAN RABARA
Credential	:	APRN
Telephone Number	:	702-677-0661

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	11/20/2017

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