Provider Demographics
NPI:1649728775
Name:DANESHFOROUZ, JACQUELYN VILLAGOMEZ (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:VILLAGOMEZ
Last Name:DANESHFOROUZ
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Gender:F
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:8530 W SUNSET RD STE 230
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2245
Mailing Address - Country:US
Mailing Address - Phone:702-483-4483
Mailing Address - Fax:702-483-4493
Practice Address - Street 1:8530 W SUNSET RD STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113
Practice Address - Country:US
Practice Address - Phone:702-483-4483
Practice Address - Fax:702-483-4493
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2018-06-13
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant