MEDICARE: IAN I CAMAHALAN PTA

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	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1790436251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN I CAMAHALAN PTA

Provider Business Mailing Address
First Line	:	5175 JERRY TARKANIAN WAY UNIT 19205
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-0013
Country	:	US
Telephone Number	:	702-727-7738
Fax Number	:

Provider Business Practice Location Address
First Line	:	5175 JERRY TARKANIAN WAY UNIT 19205
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-0013
Country	:	US
Telephone Number	:	702-381-1839
Fax Number	:

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

Provider Enumeration Date	:	01/15/2022
Last Update Date	:	01/15/2022

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Directions to “ IAN I CAMAHALAN PTA” Practice Location

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