Provider Demographics
NPI:1902366511
Name:ICHINOE, ABRAHAM TOSHINARI (DO)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:TOSHINARI
Last Name:ICHINOE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 SPANISH RIDGE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1319
Mailing Address - Country:US
Mailing Address - Phone:702-330-3102
Mailing Address - Fax:702-912-4994
Practice Address - Street 1:2880 N TENAYA WAY STE 420
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0642
Practice Address - Country:US
Practice Address - Phone:702-255-2022
Practice Address - Fax:702-255-8810
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVDO3321207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00002194567Medicaid