Provider Demographics
NPI:1689636987
Name:JIMENEZ, CARLOS E (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:E
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 E CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1826
Mailing Address - Country:US
Mailing Address - Phone:702-647-2583
Mailing Address - Fax:702-647-2511
Practice Address - Street 1:1640 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1826
Practice Address - Country:US
Practice Address - Phone:702-647-2583
Practice Address - Fax:702-647-2511
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV586363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCB952ZMedicare PIN