Basic Information
| Provider Information | |||||||||
| NPI: | 1417937558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21530 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897211530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758842455 | ||||||||
| FaxNumber: | 7758840345 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 PINE CONE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DAYTON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894037393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752460200 | ||||||||
| FaxNumber: | 7752460812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 10/08/2007 | ||||||||
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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 | 363AM0700X | PA386 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 002416066 | 05 | NV | MEDICAID |