MEDICARE: MARK GORDON VALLEJO SALVADOR APRN, NP-C

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	APRN002017	NV

General Provider Information

NPI Number	:	1841667417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK GORDON VALLEJO SALVADOR APRN, NP-C

Provider Business Mailing Address
First Line	:	10624 S EASTERN AVE
Second Line	:	APT 3-205
City	:	HENDERSON
State	:	NV
Zip	:	89052-2982
Country	:	US
Telephone Number	:	702-407-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	6352 MEDICAL CENTER ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2413
Country	:	US
Telephone Number	:	702-541-6200
Fax Number	:

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

Provider Enumeration Date	:	08/30/2015
Last Update Date	:	04/11/2016

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