Provider Demographics
NPI:1639142052
Name:LAND, THOMAS RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RAYMOND
Last Name:LAND
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 1:6970 W. PATRICK LANE
Mailing Address - Street 2:SUITE #140
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-0270
Mailing Address - Country:US
Mailing Address - Phone:702-450-1717
Mailing Address - Fax:702-947-6740
Practice Address - Street 1:6970 W. PATRICK LANE
Practice Address - Street 2:SUITE #140
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-0270
Practice Address - Country:US
Practice Address - Phone:702-450-1717
Practice Address - Fax:702-947-6740
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507214Medicaid
NV100507151Medicaid
G69695Medicare UPIN
NV100507151Medicaid