Basic Information
| Provider Information | |||||||||
| NPI: | 1629607940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC WEST UROLOGY LLC A PROFESSIONAL MEDICAL COMPANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4313 CORAN LN | ||||||||
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| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891082844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027154155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6110 ELTON AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891072538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029062976 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2020 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | EMMANUEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7027154155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.