Provider Demographics
NPI:1750532131
Name:NAVARRO, VIVENCIO C (MSN, ANP-BC)
Entity type:Individual
Prefix:
First Name:VIVENCIO
Middle Name:C
Last Name:NAVARRO
Suffix:
Gender:M
Credentials:MSN, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81345
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89180-1345
Mailing Address - Country:US
Mailing Address - Phone:702-384-5101
Mailing Address - Fax:702-382-5675
Practice Address - Street 1:2000 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4113
Practice Address - Country:US
Practice Address - Phone:702-384-5101
Practice Address - Fax:702-387-0104
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN001049363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1750532131Medicaid
NV1750532131Medicaid