Provider Demographics
NPI:1366866402
Name:MOORADIAN, JACQUI (LPTA)
Entity Type:Individual
Prefix:
First Name:JACQUI
Middle Name:
Last Name:MOORADIAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 FAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-6224
Mailing Address - Country:US
Mailing Address - Phone:702-275-6197
Mailing Address - Fax:702-242-5083
Practice Address - Street 1:6021 W. CHEYENNE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108
Practice Address - Country:US
Practice Address - Phone:702-658-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-0486225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant