Provider Demographics
NPI:1215009782
Name:PUA, ROLAND JAYSON FORMOSO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND JAYSON
Middle Name:FORMOSO
Last Name:PUA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11794 LONGWORTH RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9460 W FLAMINGO RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-5742
Practice Address - Country:US
Practice Address - Phone:702-638-7705
Practice Address - Fax:702-638-7706
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ67340207RG0300X
ORMD202126207RG0300X
CAC175306207RG0300X
ID15963207RG0300X
NV12103207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine