Basic Information
| Provider Information | |||||||||
| NPI: | 1215237110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAERLAN | ||||||||
| FirstName: | MARY-GRACE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MABASA | ||||||||
| OtherFirstName: | MARY-GRACE | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025602879 | ||||||||
| FaxNumber: | 7025602928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 RENAISSANCE DR STE C | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891196751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024345114 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN 1246 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | TAPN700611 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364SP0808X | APRN001246 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 363LP0808X | APRN001246 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.