MEDICARE: LYDIA B ESTANISLAO PLLC

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	2084N0400X	Neurology Physician		NV

General Provider Information

NPI Number	:	1770967481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYDIA B ESTANISLAO PLLC

Provider Business Mailing Address
First Line	:	4206 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1625
Country	:	US
Telephone Number	:	702-985-0118
Fax Number	:

Provider Business Practice Location Address
First Line	:	4206 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1625
Country	:	US
Telephone Number	:	702-985-0118
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	LYDIA B ESTANISLAO
Credential	:	MD
Telephone Number	:	702-985-0118

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/13/2015

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