Provider Demographics
NPI:1366001950
Name:MARIANO, GERARDO A
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:A
Last Name:MARIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4462 FARMCREST DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4906
Mailing Address - Country:US
Mailing Address - Phone:702-433-2879
Mailing Address - Fax:702-433-2879
Practice Address - Street 1:4462 FARMCREST DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4906
Practice Address - Country:US
Practice Address - Phone:702-433-2879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV297-AGC-323104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV260502327Medicaid