Provider Demographics
NPI:1306489331
Name:CULANAG, MARK JOEL RIVERA (NP-C)
Entity type:Individual
Prefix:
First Name:MARK JOEL
Middle Name:RIVERA
Last Name:CULANAG
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6843 W TROPICANA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4923
Mailing Address - Country:US
Mailing Address - Phone:702-888-1113
Mailing Address - Fax:725-204-5236
Practice Address - Street 1:6843 W TROPICANA AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4923
Practice Address - Country:US
Practice Address - Phone:702-888-1113
Practice Address - Fax:725-204-5236
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV825001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250004418Medicaid