Provider Demographics
NPI:1184062309
Name:TAITANO, JOHNATHAN RYAN (DO)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:RYAN
Last Name:TAITANO
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 1:1980 FESTIVAL PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-2930
Mailing Address - Country:US
Mailing Address - Phone:702-704-5207
Mailing Address - Fax:702-602-9486
Practice Address - Street 1:241 N BUFFALO DR STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0312
Practice Address - Country:US
Practice Address - Phone:702-347-7000
Practice Address - Fax:702-202-6401
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL0955174400000X
NVDO2144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1184062309Medicaid
NVDO2144OtherSTATE LICENSE