Basic Information
| Provider Information | |||||||||
| NPI: | 1629495759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGASTYA | ||||||||
| FirstName: | MANAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 W CHARLESTON BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022319 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1707 W CHARLESTON BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026712345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 17194 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629495759 | 05 | NV | MEDICAID |