Provider Demographics
NPI:1396028619
Name:EDGAR EVANGELISTA MD PC
Entity Type:Organization
Organization Name:EDGAR EVANGELISTA MD PC
Other - Org Name:NEVADA NEUROLOGIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:JAY B
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-800-7831
Mailing Address - Street 1:1452 W HORIZON RIDGE PKWY # 566
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4422
Mailing Address - Country:US
Mailing Address - Phone:702-800-7831
Mailing Address - Fax:877-409-2014
Practice Address - Street 1:2110 E FLAMINGO RD STE 201
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5192
Practice Address - Country:US
Practice Address - Phone:702-800-7831
Practice Address - Fax:877-409-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic NeuroimagingGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCE661AMedicare PIN