Basic Information
| Provider Information | |||||||||
| NPI: | 1376514034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POPE | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027503900 | ||||||||
| FaxNumber: | 7027503853 | ||||||||
| Practice Location | |||||||||
| Address1: | 7061 GRAND MONTECITO PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891490287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027503900 | ||||||||
| FaxNumber: | 7027503853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | PA 8960 | NV | N | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | PA896 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100505472 | 05 | NV | MEDICAID | 100505473 | 01 | NV | MEDICAID | OTHER |