Provider Demographics
NPI:1780443036
Name:KHANUKAYEV, BORIS MAKSIMOVICH (DO)
Entity type:Individual
Prefix:DR
First Name:BORIS
Middle Name:MAKSIMOVICH
Last Name:KHANUKAYEV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N TENAYA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0436
Mailing Address - Country:US
Mailing Address - Phone:702-962-5000
Mailing Address - Fax:
Practice Address - Street 1:3100 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0436
Practice Address - Country:US
Practice Address - Phone:702-962-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty