Basic Information
| Provider Information | |||||||||
| NPI: | 1790447365 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULSON | ||||||||
| FirstName: | LYNDA | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9454 MAGNIFICENT AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891484590 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6295 MCLEOD DR STE 15 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891204434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022703219 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2021 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-21-183168 | NV | Y |
No ID Information.