Provider Demographics
NPI:1366015711
Name:PAKINGAN, XAVIERRE
Entity Type:Individual
Prefix:
First Name:XAVIERRE
Middle Name:
Last Name:PAKINGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 SUN COPPER DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7020
Mailing Address - Country:US
Mailing Address - Phone:213-793-3175
Mailing Address - Fax:
Practice Address - Street 1:1404 SUN COPPER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7020
Practice Address - Country:US
Practice Address - Phone:213-793-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU291386Medicaid