Provider Demographics
NPI:1811967912
Name:EBBIN, ALLAN JEROME (MD)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:JEROME
Last Name:EBBIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:702-240-8847
Mailing Address - Fax:702-240-8790
Practice Address - Street 1:2716-4 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128
Practice Address - Country:US
Practice Address - Phone:702-242-7731
Practice Address - Fax:702-869-2480
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8037208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3102835Medicaid
NVP00012602OtherRAILROAD MEDICARE
NV2018835Medicaid
E29431Medicare UPIN
NV37393Medicare ID - Type Unspecified