Provider Demographics
NPI:1831675768
Name:IRVIN, JOHNATHAN
Entity Type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:
Last Name:IRVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 N RAINBOW BLVD UNIT 2118
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4513
Mailing Address - Country:US
Mailing Address - Phone:702-752-7606
Mailing Address - Fax:
Practice Address - Street 1:2950 E FLAMINGO RD STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5208
Practice Address - Country:US
Practice Address - Phone:702-586-9674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker