Basic Information
| Provider Information | |||||||||
| NPI: | 1235890062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POKROY MEDICAL GROUP OF NEVADA, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 50978 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 SAINT ROSE PKWY | ||||||||
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| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026165000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2022 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | DEETER | ||||||||
| AuthorizedOfficialFirstName: | KRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7759826169 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1992809412 | 05 | NV | MEDICAID |