Basic Information
| Provider Information | |||||||||
| NPI: | 1326099235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANPOCO | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 W OAKEY BLVD | ||||||||
| Address2: | # 4A | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684347 | ||||||||
| FaxNumber: | 7023825388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3196 S MARYLAND PARKWAY | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029442888 | ||||||||
| FaxNumber: | 7029442890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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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 | 207V00000X | 00C508220 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 12575 | NV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1043285216 | 05 | NV | MEDICAID | 00C508220 | 05 | CA | MEDICAID |