| |
3620 N Rancho Dr Ste 103&104 Las Vegas NV 89130-3155 | |
(725) 712-4625 | |
(725) 262-5536 |
Full Name | |
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Speciality | Family Medicine |
Location | 3620 N Rancho Dr Ste 103&104, Las Vegas, Nevada |
Authorized Official Name and Position | Ebony Shandreka Peterson (MANAGING MEMBER/ NURSE PRACTITIONER) |
Authorized Official Contact | 7023502032 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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3620 N Rancho Dr Ste 103&104 Las Vegas NV 89130-3155 Ph: (725) 712-4625 | 3620 N Rancho Dr Ste 103&104 Las Vegas NV 89130-3155 Ph: (725) 712-4625 |
NPI Number | 1871291872 |
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Provider Enumeration Date | 02/20/2023 |
Last Update Date | 01/27/2025 |
Medicare PECOS PAC ID | 6507306198 |
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Medicare Enrollment ID | O20240910002829 |
Identifier | Type | State | Issuer |
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1871291872 | NPI | - | NPPES |
Provider Name | Ebony Peterson |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1396293841 PECOS PAC ID: 9133417645 Enrollment ID: I20200319002443 |
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