Provider Demographics
NPI:1912662081
Name:GUBATON, ROSE LILY G
Entity Type:Individual
Prefix:MRS
First Name:ROSE LILY
Middle Name:G
Last Name:GUBATON
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 1:500 S RANCHO DR
Mailing Address - Street 2:STE 12
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4852
Mailing Address - Country:US
Mailing Address - Phone:702-877-1887
Mailing Address - Fax:702-877-4536
Practice Address - Street 1:500 S RANCHO DR STE 12
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4852
Practice Address - Country:US
Practice Address - Phone:702-877-1887
Practice Address - Fax:702-877-4536
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN848060363L00000X
NV40921163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1912662081Medicaid