Provider Demographics
NPI:1275822611
Name:GODOY, MARIO OLIVER TABLANTE (APRN NP-C)
Entity Type:Individual
Prefix:MR
First Name:MARIO OLIVER
Middle Name:TABLANTE
Last Name:GODOY
Suffix:
Gender:M
Credentials:APRN NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8010 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-2016
Mailing Address - Country:US
Mailing Address - Phone:702-239-9123
Mailing Address - Fax:
Practice Address - Street 1:1706 W BONANZA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4704
Practice Address - Country:US
Practice Address - Phone:702-631-6860
Practice Address - Fax:702-631-6864
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN001258163W00000X
NVRN67477163W00000X
NVAPRN001258363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse