Basic Information
Provider Information
NPI: 1033556279
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EVASCO
FirstName: NESTOR
MiddleName: C
NamePrefix: MR.
NameSuffix: JR.
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 549 SIERRA VISTA DR
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891693764
CountryCode: US
TelephoneNumber: 7023557783
FaxNumber:  
Practice Location
Address1: 3680 N RANCHO DR
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891303180
CountryCode: US
TelephoneNumber: 7028694300
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/29/2013
LastUpdateDate: 05/29/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103K00000X  Y Behavioral Health & Social Service ProvidersBehavioral Analyst 

No ID Information.


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