Basic Information
| Provider Information | |||||||||
| NPI: | 1235427816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COULIBALY | ||||||||
| FirstName: | SURURAT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025602879 | ||||||||
| FaxNumber: | 7025602928 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 S RANCHO DR STE E | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022581001 | ||||||||
| FaxNumber: | 7022583455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2011 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA21484 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA1271 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA1271 | 01 | NV | MEDICAL LICENSE | OTHER | 1235427816 | 05 | NV | MEDICAID |