Provider Demographics
NPI:1003295189
Name:ANNETTE F MAYES MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ANNETTE F MAYES MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-522-9640
Mailing Address - Street 1:700 SHADOW LANE
Mailing Address - Street 2:SUITE 165
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106
Mailing Address - Country:US
Mailing Address - Phone:702-522-9640
Mailing Address - Fax:
Practice Address - Street 1:700 SHADOW LN
Practice Address - Street 2:SUITE 165
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4126
Practice Address - Country:US
Practice Address - Phone:702-522-9640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7200305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV35155OtherMEDICARE PTAN
NV2019271Medicaid