Provider Demographics
NPI:1124167440
Name:KODANDAPANI, KESHAVAN (APN)
Entity type:Individual
Prefix:
First Name:KESHAVAN
Middle Name:
Last Name:KODANDAPANI
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W. CHARLESTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-383-2688
Mailing Address - Fax:702-952-3364
Practice Address - Street 1:5757 WAYNE NEWTON BLVD.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89111
Practice Address - Country:US
Practice Address - Phone:702-383-2527
Practice Address - Fax:702-383-1991
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000923164W00000X
NVAPRN000923363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV112285Medicare PIN