Provider Demographics
NPI:1124357967
Name:NANA K ERICSSON MD PC
Entity Type:Organization
Organization Name:NANA K ERICSSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ERICSSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-557-3221
Mailing Address - Street 1:2110 E FLAMINGO RD
Mailing Address - Street 2:SUITE 313
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5190
Mailing Address - Country:US
Mailing Address - Phone:702-577-3221
Mailing Address - Fax:702-517-5807
Practice Address - Street 1:2110 E FLAMINGO RD
Practice Address - Street 2:SUITE 313
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5190
Practice Address - Country:US
Practice Address - Phone:702-577-3221
Practice Address - Fax:702-517-5807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV8B8667Medicare PIN