MEDICARE: MR. RICHARD E O'BRINGER JR. PAC

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	363AS0400X	Surgical Physician Assistant	PA626	NV

General Provider Information

NPI Number	:	1710937446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD E O'BRINGER JR. PAC

Provider Business Mailing Address
First Line	:	11413 PERUGINO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-1533
Country	:	US
Telephone Number	:	702-499-7296
Fax Number	:	702-254-9190

Provider Business Practice Location Address
First Line	:	11413 PERUGINO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-1533
Country	:	US
Telephone Number	:	702-499-7296
Fax Number	:	702-254-9190

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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