Provider Demographics
NPI:1235427816
Name:COULIBALY, SURURAT A (PA-C)
Entity Type:Individual
Prefix:
First Name:SURURAT
Middle Name:A
Last Name:COULIBALY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-560-2879
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:630 S RANCHO DR STE E
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4849
Practice Address - Country:US
Practice Address - Phone:702-258-1001
Practice Address - Fax:702-258-3455
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21484363AM0700X
NVPA1271363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA1271OtherMEDICAL LICENSE
NV1235427816Medicaid
NVFL006YMedicare PIN
NVFL006ZMedicare PIN