Basic Information
| Provider Information | |||||||||
| NPI: | 1730715129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | IM | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MA | ||||||||
| OtherFirstName: | RINOA | ||||||||
| OtherMiddleName: | IM IENG | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2110 E FLAMINGO RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891195190 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2110 E FLAMINGO RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891195190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022703219 | ||||||||
| FaxNumber: | 8668332056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2020 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.