Provider Demographics
NPI:1629451315
Name:HAN, BRENT (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:HAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 S DECATUR BLVD STE 25
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5857
Mailing Address - Country:US
Mailing Address - Phone:725-224-6967
Mailing Address - Fax:833-749-0357
Practice Address - Street 1:4001 S DECATUR BLVD STE 25
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5857
Practice Address - Country:US
Practice Address - Phone:725-224-6967
Practice Address - Fax:833-749-0357
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15879207Q00000X
NVDO02543207Q00000X
WVED0502A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV73854OtherMEDICARE
NV1629451315Medicaid