Provider Demographics
NPI:1407636053
Name:CASANOVA VERGARAY, ALEJANDRO VICENTE
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:VICENTE
Last Name:CASANOVA VERGARAY
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 1:3710 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8030
Mailing Address - Country:US
Mailing Address - Phone:308-440-8494
Mailing Address - Fax:
Practice Address - Street 1:816 22ND AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2234
Practice Address - Country:US
Practice Address - Phone:308-865-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE115067363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care