Provider Demographics
NPI:1669660221
Name:BAZILE, QUANETTA LINDA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:QUANETTA
Middle Name:LINDA
Last Name:BAZILE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:3186 S MARYLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2317
Mailing Address - Country:US
Mailing Address - Phone:702-961-7310
Mailing Address - Fax:844-231-4920
Practice Address - Street 1:3186 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2317
Practice Address - Country:US
Practice Address - Phone:702-961-7310
Practice Address - Fax:844-231-4920
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2020-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXPA05764363A00000X
MI5601004715363A00000X
NVPA1703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669660221Medicare UPIN