Provider Demographics
NPI:1861630444
Name:GARRETT, STEPHAN T (PAC)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:T
Last Name:GARRETT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 N TENAYA WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0464
Mailing Address - Country:US
Mailing Address - Phone:702-252-8378
Mailing Address - Fax:702-242-0098
Practice Address - Street 1:2911 N TENAYA WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0464
Practice Address - Country:US
Practice Address - Phone:702-252-8378
Practice Address - Fax:702-242-0098
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant