Provider Demographics
NPI:1093148439
Name:MARS, DEIDRA E
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:E
Last Name:MARS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4773 CAUGHLIN PKWY
Mailing Address - Street 2:4773 CAUGHLIN PARKWAY SUITE2
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-1011
Mailing Address - Country:US
Mailing Address - Phone:775-677-2216
Mailing Address - Fax:
Practice Address - Street 1:4773 CAUGHLIN PKWY STE 2
Practice Address - Street 2:4773 CAUGHLIN PKWY SUITE2
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89519-1012
Practice Address - Country:US
Practice Address - Phone:775-677-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker