1992774152 NPI number — GERARD JOHN CONNELLY PAC

Table of content: GERARD JOHN CONNELLY PAC (NPI 1992774152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992774152 NPI number — GERARD JOHN CONNELLY PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNELLY
Provider First Name:
GERARD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1992774152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3196 S MARYLAND PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-731-8099
Provider Business Mailing Address Fax Number:
702-731-8292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6900 N PECOS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
N LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89086-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-791-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2006

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: 363A00000X , with the licence number:  PA873 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA873 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100504648 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 991530 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".