Provider Demographics
NPI:1477138626
Name:MARPAUNG, JESRON
Entity Type:Individual
Prefix:
First Name:JESRON
Middle Name:
Last Name:MARPAUNG
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 1:6540 BLACK OAKS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2045
Mailing Address - Country:US
Mailing Address - Phone:909-913-8647
Mailing Address - Fax:
Practice Address - Street 1:6540 BLACK OAKS ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-2045
Practice Address - Country:US
Practice Address - Phone:909-913-8647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVF10201409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily