Basic Information
| Provider Information | |||||||||
| NPI: | 1043259070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRERA BAUMANN | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | ELIZABETH NICOLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WANYIK-FERRERA | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6330 S JONES BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891183302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028807002 | ||||||||
| FaxNumber: | 7028809444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1835 ODDIE BLVD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894313559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825140 | ||||||||
| FaxNumber: | 7759825141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12495 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11174425 | 01 | CAQH | OTHER | 1043259070 | 05 | NV | MEDICAID |