Basic Information
| Provider Information | |||||||||
| NPI: | 1699763466 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISGORE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 W CHARLESTON BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028779514 | ||||||||
| FaxNumber: | 7023123510 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 E CALVADA BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PAHRUMP | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890485824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757511555 | ||||||||
| FaxNumber: | 7757511551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA737 | NV | X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA737 | NV | X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.