Provider Demographics
NPI:1508824913
Name:ERICSSON, NANA (MD)
Entity Type:Individual
Prefix:
First Name:NANA
Middle Name:
Last Name:ERICSSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S RAINBOW BLVD
Mailing Address - Street 2:108
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-4006
Mailing Address - Country:US
Mailing Address - Phone:702-921-6823
Mailing Address - Fax:702-921-6821
Practice Address - Street 1:3540 W SAHARA AVE
Practice Address - Street 2:330
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-5816
Practice Address - Country:US
Practice Address - Phone:702-921-6823
Practice Address - Fax:702-921-6821
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV11476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507057Medicaid