Provider Demographics
NPI:1386896835
Name:UNIVERSITY OF NV SCHOOL OF MEDICINE MUTLI SPECIALTY GROUP PRACTICE SO
Entity type:Organization
Organization Name:UNIVERSITY OF NV SCHOOL OF MEDICINE MUTLI SPECIALTY GROUP PRACTICE SO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZAMBONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-671-2278
Mailing Address - Street 1:PO BOX 98528
Mailing Address - Street 2:DEPT 401
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8528
Mailing Address - Country:US
Mailing Address - Phone:702-671-2395
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:1391 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1200
Practice Address - Country:US
Practice Address - Phone:702-486-6200
Practice Address - Fax:702-486-6368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8762207Q00000X
NV10440207QS0010X
NVAPN00227363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500484Medicaid
NV100500484Medicaid