Basic Information
| Provider Information | |||||||||
| NPI: | 1194812438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASQUEZ | ||||||||
| FirstName: | CARLO | ||||||||
| MiddleName: | MARIO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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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: | 10/06/2006 | ||||||||
| 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 | 363A00000X | 633 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 588 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1194812438 | 01 | NV | SMA MEDICAID | OTHER | V111167 | 01 | NV | SMA MEDICARE | OTHER |