Provider Demographics
NPI:1083378657
Name:FAJARDO, DENNIS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6288 HUMUS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-5457
Mailing Address - Country:US
Mailing Address - Phone:702-639-7699
Mailing Address - Fax:
Practice Address - Street 1:330 S CASINO CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6102
Practice Address - Country:US
Practice Address - Phone:702-671-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60732363AM0700X
NVPA2469363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical