Basic Information
| Provider Information | |||||||||
| NPI: | 1275755670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICUNA | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N STEPHANIE ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523350 | ||||||||
| FaxNumber: | 7029523365 | ||||||||
| Practice Location | |||||||||
| Address1: | 653 N TOWN CENTER DR STE 402 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891440518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022437200 | ||||||||
| FaxNumber: | 7022289410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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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 | 207RX0202X | 12251 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 12251 | 01 | NV | MD LICENSE | OTHER |