Provider Demographics
NPI:1184867301
Name:NYDAM, ROBERT GREGORY (IDMT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GREGORY
Last Name:NYDAM
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8600
Mailing Address - Fax:702-258-6152
Practice Address - Street 1:888 S RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3810
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-258-6152
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1003X
NV363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1184867301Medicaid
NVV112613Medicare PIN