Provider Demographics
NPI:1891380481
Name:BRAUN, ROGER T (PA-C)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:T
Last Name:BRAUN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E DESERT INN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3609
Mailing Address - Country:US
Mailing Address - Phone:702-731-1616
Mailing Address - Fax:702-734-4900
Practice Address - Street 1:2800 E DESERT INN RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3609
Practice Address - Country:US
Practice Address - Phone:702-294-7402
Practice Address - Fax:702-734-4900
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2422363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1891380481Medicaid
NVPA2422OtherMEDICAL LICENSE