Provider Demographics
NPI:1497506463
Name:NICOLAS, JEROME AGULLANA
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:AGULLANA
Last Name:NICOLAS
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 1:6251 SIERRA KNOLLS CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7208
Mailing Address - Country:US
Mailing Address - Phone:702-301-4770
Mailing Address - Fax:
Practice Address - Street 1:6251 SIERRA KNOLLS CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7208
Practice Address - Country:US
Practice Address - Phone:702-301-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV874921363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty