Provider Demographics
NPI:1992992978
Name:GUILLERMO FRAGA, M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GUILLERMO FRAGA, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:HUGO
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-452-3002
Mailing Address - Street 1:2649 WIGWAM PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7310
Mailing Address - Country:US
Mailing Address - Phone:702-452-3002
Mailing Address - Fax:
Practice Address - Street 1:2649 WIGWAM PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7310
Practice Address - Country:US
Practice Address - Phone:702-452-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7867261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV02663OtherMEDICARE EDI
NV002019808Medicaid
NV101047OtherGROUP PIN
NV101048Medicare PIN
NVG35519Medicare UPIN