Basic Information
| Provider Information | |||||||||
| NPI: | 1144344599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PASSALACQUA | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 WEST 2ND STREET | ||||||||
| Address2: | #227, NELSON BLDG. MS 353 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757841223 | ||||||||
| FaxNumber: | 7753272006 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 17TH STREET | ||||||||
| Address2: | BRIGHAM BLDG. MAIL STOP 316 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757841533 | ||||||||
| FaxNumber: | 7757848075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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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 | 207Q00000X | 6822 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100506503 | 05 | NV | MEDICAID |