Provider Demographics
NPI:1760090419
Name:RODRIGUEZ, JUAN CARLOS SALACUP (APRN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JUAN CARLOS
Middle Name:SALACUP
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 W RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1919
Mailing Address - Country:US
Mailing Address - Phone:702-396-4165
Mailing Address - Fax:702-252-4405
Practice Address - Street 1:6480 W RUSSELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1919
Practice Address - Country:US
Practice Address - Phone:702-396-4165
Practice Address - Fax:702-252-4405
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVTEMP832426363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily