Provider Demographics
NPI:1245999820
Name:ERTLE, ELIZABETH ANN (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:ERTLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:KENNELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:7200 CATHEDRAL ROCK DR STE 180
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0466
Mailing Address - Country:US
Mailing Address - Phone:702-341-9000
Mailing Address - Fax:702-341-5864
Practice Address - Street 1:330 S CASINO CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6102
Practice Address - Country:US
Practice Address - Phone:702-671-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant