Provider Demographics
NPI:1144252826
Name:GAUTHIER, MARY ELLEN (APRN-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:888 W BONNEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-0100
Mailing Address - Country:US
Mailing Address - Phone:702-483-6000
Mailing Address - Fax:702-483-6039
Practice Address - Street 1:4505 S. MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89154-3020
Practice Address - Country:US
Practice Address - Phone:702-895-0540
Practice Address - Fax:702-895-4316
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-04-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NVAPN00508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP97254Medicare UPIN