Basic Information
| Provider Information | |||||||||
| NPI: | 1831244425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION | ||||||||
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| OtherOrganizationName: | CARSON VALLEY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 US HIGHWAY 395 N | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894105304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821500 | ||||||||
| FaxNumber: | 7757834849 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 HIGHWAY 395 | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821500 | ||||||||
| FaxNumber: | 7757821555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PRATER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7757821500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1831244425 | 01 | NV | MEDICARE NPI | OTHER | 100503333 | 05 | NV | MEDICAID |