Provider Demographics
NPI:1275029092
Name:GASCON, MAVIES FERMIN (LMY, MMP)
Entity Type:Individual
Prefix:
First Name:MAVIES
Middle Name:FERMIN
Last Name:GASCON
Suffix:
Gender:M
Credentials:LMY, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W CHICAGO AVE APT D
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2825
Mailing Address - Country:US
Mailing Address - Phone:702-917-5098
Mailing Address - Fax:
Practice Address - Street 1:7455 W WASHINGTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4338
Practice Address - Country:US
Practice Address - Phone:702-489-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.6495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist