Provider Demographics
NPI:1104632876
Name:KEUSSEYAN, SIBOUH SAM
Entity type:Individual
Prefix:MR
First Name:SIBOUH
Middle Name:SAM
Last Name:KEUSSEYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 SAINT ROSE PKWY UNIT 778051
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89077-8843
Mailing Address - Country:US
Mailing Address - Phone:702-686-6284
Mailing Address - Fax:
Practice Address - Street 1:2605 VENDANGE PL
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89044-0451
Practice Address - Country:US
Practice Address - Phone:702-686-6284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant