Provider Demographics
NPI:1043735871
Name:PURDUM, ALICIA LAURIE (BOCO, BOCP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LAURIE
Last Name:PURDUM
Suffix:
Gender:F
Credentials:BOCO, BOCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 S DURANGO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-2487
Mailing Address - Country:US
Mailing Address - Phone:702-932-1300
Mailing Address - Fax:702-848-4990
Practice Address - Street 1:810 S DURANGO DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-2487
Practice Address - Country:US
Practice Address - Phone:702-932-1300
Practice Address - Fax:702-848-4990
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVC52329224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist