Provider Demographics
NPI:1487746459
Name:GRACE, BRIAN EDWARD (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:GRACE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5188 BLISSFUL VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-5262
Mailing Address - Country:US
Mailing Address - Phone:702-373-9929
Mailing Address - Fax:800-886-2862
Practice Address - Street 1:5188 BLISSFUL VALLEY CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-5262
Practice Address - Country:US
Practice Address - Phone:702-373-9929
Practice Address - Fax:800-886-2862
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA727363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002402144Medicaid
NV731645266OtherTIN #
NVP70232Medicare UPIN
NVV37842Medicare ID - Type Unspecified