Provider Demographics
NPI:1417949314
Name:PHAN, TIMOTHY (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7385 S PECOS RD
Mailing Address - Street 2:STE 103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3768
Mailing Address - Country:US
Mailing Address - Phone:888-221-2297
Mailing Address - Fax:
Practice Address - Street 1:330 S LOLA LN
Practice Address - Street 2:SUITE 200
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-0878
Practice Address - Country:US
Practice Address - Phone:775-751-7500
Practice Address - Fax:775-751-7824
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCRNA000265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505726Medicaid
NV100505726Medicaid