Provider Demographics
NPI:1821026824
Name:PRIMARY CARE OF SOUTHERN NEVADA
Entity Type:Organization
Organization Name:PRIMARY CARE OF SOUTHERN NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ELAN
Authorized Official - Last Name:VAN WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-990-0333
Mailing Address - Street 1:2225 VILLAGE WALK DR
Mailing Address - Street 2:SUITE 270
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5679
Mailing Address - Country:US
Mailing Address - Phone:702-993-0333
Mailing Address - Fax:702-990-0336
Practice Address - Street 1:2225 VILLAGE WALK DR
Practice Address - Street 2:SUITE 270
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5679
Practice Address - Country:US
Practice Address - Phone:702-993-0333
Practice Address - Fax:702-990-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV33715Medicare PIN