Provider Demographics
NPI:1497506463
Name:NICOLAS, JEROME AGULLANA (APRN)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:AGULLANA
Last Name:NICOLAS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5380 S RAINBOW BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1878
Mailing Address - Country:US
Mailing Address - Phone:725-333-8465
Mailing Address - Fax:725-333-8466
Practice Address - Street 1:5380 S RAINBOW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1878
Practice Address - Country:US
Practice Address - Phone:725-333-8465
Practice Address - Fax:725-333-8466
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV874921363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty