Provider Demographics
NPI:1114393568
Name:MCGINNIS MICA MEDICAL PC
Entity Type:Organization
Organization Name:MCGINNIS MICA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:702-706-4362
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:BEATTY
Mailing Address - State:NV
Mailing Address - Zip Code:89003-0300
Mailing Address - Country:US
Mailing Address - Phone:702-706-4362
Mailing Address - Fax:877-991-6606
Practice Address - Street 1:1550 W ELLIOTT AVE
Practice Address - Street 2:# 300
Practice Address - City:BEATTY
Practice Address - State:NV
Practice Address - Zip Code:89003-0300
Practice Address - Country:US
Practice Address - Phone:702-706-4362
Practice Address - Fax:877-991-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001078363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1114393568Medicaid