Provider Demographics
NPI:1477579829
Name:VENDITTI, GINA NICOLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:NICOLE
Last Name:VENDITTI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3758 LAS VEGAS BLVD S
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-4132
Mailing Address - Country:US
Mailing Address - Phone:702-262-9028
Mailing Address - Fax:702-736-3921
Practice Address - Street 1:3758 LAS VEGAS BLVD S
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-4132
Practice Address - Country:US
Practice Address - Phone:702-262-9028
Practice Address - Fax:702-736-3921
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102437363A00000X
NVPA 1224363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q25018Medicare UPIN
FLU3312ZMedicare ID - Type UnspecifiedMEDICARE