Provider Demographics
NPI:1124429964
Name:ESTEBAN, MARYANA IV
Entity type:Individual
Prefix:MS
First Name:MARYANA
Middle Name:
Last Name:ESTEBAN
Suffix:IV
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4348 LA JARA DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1526
Mailing Address - Country:US
Mailing Address - Phone:702-689-8670
Mailing Address - Fax:
Practice Address - Street 1:4348 LA JARA DR.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120
Practice Address - Country:US
Practice Address - Phone:702-689-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV201311504903747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1487056909Medicaid