Provider Demographics
NPI:1255304523
Name:BURGUILLOS, KAREN BROTARLO (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:BROTARLO
Last Name:BURGUILLOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:GRACE
Other - Last Name:BROTARLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10011 BLAIRWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-4830
Mailing Address - Country:US
Mailing Address - Phone:702-858-8615
Mailing Address - Fax:702-822-5001
Practice Address - Street 1:4100 W FLAMINGO RD STE 2100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3926
Practice Address - Country:US
Practice Address - Phone:702-822-5000
Practice Address - Fax:702-822-5001
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA765363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3102202Medicaid
NV2402212Medicaid
NV2402212Medicaid
NV37191Medicare ID - Type Unspecified
NV3102202Medicaid