Provider Demographics
NPI:1922267764
Name:VESAGAS, MYRA JUNE S (PT)
Entity Type:Individual
Prefix:
First Name:MYRA JUNE
Middle Name:S
Last Name:VESAGAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 26299
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89126-0299
Mailing Address - Country:US
Mailing Address - Phone:702-893-3333
Mailing Address - Fax:702-893-0960
Practice Address - Street 1:4275 BURNHAM AVE.
Practice Address - Street 2:SUITE 255
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-8204
Practice Address - Country:US
Practice Address - Phone:702-380-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1053594937Medicaid
NV001702161Medicaid
NVCCN294507Medicare PIN
NV294507Medicare PIN