Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | AI070134 | MI |
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 12082 | NV |
NPI | 1114901444 |
---|---|
Provider Name | Alexander Imas |
First Address | Henderson, NV 89053-1666 |
Second Address | Henderson, NV 89012-5725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2005 |
Last Update Date | 31/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1376795823 | GROUP NPI (01) | NV |
H67364 | (02) | MI |