Provider Demographics
NPI:1073529822
Name:BUITRAGO, JENNIFER (CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BUITRAGO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10170 W TROPICANA AVE # 156-252
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8465
Mailing Address - Country:US
Mailing Address - Phone:702-732-1493
Mailing Address - Fax:702-732-1080
Practice Address - Street 1:1 BREAKTHROUGH WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-3011
Practice Address - Country:US
Practice Address - Phone:702-732-1493
Practice Address - Fax:702-732-1080
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000838363LP0200X
CA67914363LP0200X
CA536283363LP0200X
NVAPRN000838363L00000X, 363LP0200X
CA12738363LP0200X
NVRN47814363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506201Medicaid
NV100510598Medicaid
NV100506201Medicaid