Basic Information
| Provider Information | |||||||||
| NPI: | 1033201082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICUNA | ||||||||
| FirstName: | JOSELO | ||||||||
| MiddleName: | ATIENZA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98978 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891938978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025072486 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 2365 REYNOLDS AVE | ||||||||
| Address2: | 211 | ||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890307276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023991287 | ||||||||
| FaxNumber: | 7026498064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 3370 | NV | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1033201082 | 05 | NV | MEDICAID |