1760090419 NPI number — MR. JUAN CARLOS SALACUP RODRIGUEZ APRN, FNP-C

Table of content: MR. JUAN CARLOS SALACUP RODRIGUEZ APRN, FNP-C (NPI 1760090419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760090419 NPI number — MR. JUAN CARLOS SALACUP RODRIGUEZ APRN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
JUAN CARLOS
Provider Middle Name:
SALACUP
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760090419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6480 W RUSSELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89118-1919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-396-4165
Provider Business Mailing Address Fax Number:
702-252-4405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6480 W RUSSELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89118-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-396-4165
Provider Business Practice Location Address Fax Number:
702-252-4405
Provider Enumeration Date:
07/20/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  TEMP832426 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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