Basic Information
| Provider Information | |||||||||
| NPI: | 1184867301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYDAM | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | IDMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028778600 | ||||||||
| FaxNumber: | 7022586152 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 S RANCHO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891063810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028778600 | ||||||||
| FaxNumber: | 7022586152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2009 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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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 | 1710I1003X | N | Other Service Providers | Military Health Care Provider | Independent Duty Medical Technicians | 363A00000X | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1184867301 | 05 | NV | MEDICAID |