Provider Demographics
NPI:1073967022
Name:AFFILIATED PODIATRY LLC
Entity Type:Organization
Organization Name:AFFILIATED PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMESON
Authorized Official - Middle Name:B
Authorized Official - Last Name:NOORDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-456-1441
Mailing Address - Street 1:68 N PECOS RD
Mailing Address - Street 2:STE A
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074
Mailing Address - Country:US
Mailing Address - Phone:702-456-1441
Mailing Address - Fax:702-456-3901
Practice Address - Street 1:68 N PECOS RD
Practice Address - Street 2:STE A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074
Practice Address - Country:US
Practice Address - Phone:702-456-1441
Practice Address - Fax:702-456-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty