Provider Demographics
NPI:1740962430
Name:BANCORO, CLARISSA M
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:M
Last Name:BANCORO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9975 PEACE WAY UNIT 2090
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8268
Mailing Address - Country:US
Mailing Address - Phone:559-285-5032
Mailing Address - Fax:
Practice Address - Street 1:9975 PEACE WAY UNIT 2090
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8268
Practice Address - Country:US
Practice Address - Phone:559-285-5032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05067412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer