Basic Information
| Provider Information | |||||||||
| NPI: | 1316173891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN CRITICAL CARE ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN CRITICAL CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 371353 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891371353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022339222 | ||||||||
| FaxNumber: | 7026854246 | ||||||||
| Practice Location | |||||||||
| Address1: | 10300 W CHARLESTON BLVD STE 13-342 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891351037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022339222 | ||||||||
| FaxNumber: | 7028041349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 03/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | WATANABE | ||||||||
| AuthorizedOfficialFirstName: | WILSON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7022339222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.