Provider Demographics
NPI:1053301580
Name:PERNELL, ANDREA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:PERNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400205
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89140-0205
Mailing Address - Country:US
Mailing Address - Phone:702-566-2455
Mailing Address - Fax:702-870-2214
Practice Address - Street 1:2810 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 48
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1921
Practice Address - Country:US
Practice Address - Phone:702-870-2213
Practice Address - Fax:702-870-2214
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2013-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7834208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018046Medicaid
NVFK081ZMedicare PIN
NVE92797Medicare UPIN