Provider Demographics
NPI:1336531417
Name:WANTIG AZCARRAGA, JUAN E (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:E
Last Name:WANTIG AZCARRAGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN-ENRIQUE
Other - Middle Name:
Other - Last Name:WANTIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8352 W WARM SPRINGS RD STE 210
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3630
Mailing Address - Country:US
Mailing Address - Phone:702-944-4028
Mailing Address - Fax:702-944-4019
Practice Address - Street 1:8352 W WARM SPRINGS RD STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-3630
Practice Address - Country:US
Practice Address - Phone:702-944-4028
Practice Address - Fax:702-944-4019
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17337208000000X
FL21006208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138808OtherLICENSE