Provider Demographics
NPI:1952925513
Name:BANZON, MELVIN
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:BANZON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3095 TARPON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1198
Mailing Address - Country:US
Mailing Address - Phone:702-580-3157
Mailing Address - Fax:
Practice Address - Street 1:6765 W CHARLESTON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-2001
Practice Address - Country:US
Practice Address - Phone:702-852-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV829626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty