MEDICARE: LISA ELAINE AGNEW

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	174400000X	Specialist	NVMT.0766	NV

General Provider Information

NPI Number	:	1780873802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ELAINE AGNEW

Provider Business Mailing Address
First Line	:	PO BOX 28254
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89126-2254
Country	:	US
Telephone Number	:	702-274-0054
Fax Number	:

Provider Business Practice Location Address
First Line	:	1049 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-6232
Country	:	US
Telephone Number	:	702-274-0054
Fax Number	:

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

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	06/09/2011

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Directions to “ LISA ELAINE AGNEW ” Practice Location

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