Provider Demographics
NPI:1720228612
Name:RADIVAN, JESSICA E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:E
Last Name:RADIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:E
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8600
Mailing Address - Fax:702-258-6152
Practice Address - Street 1:888 S RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3810
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-258-6152
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1146363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV110828OtherSMA MEDICARE
NV1720228612Medicaid
NV1720228612Medicaid