Provider Demographics
NPI:1730944190
Name:INFANTADO, JUAN MIGUEL
Entity type:Individual
Prefix:
First Name:JUAN MIGUEL
Middle Name:
Last Name:INFANTADO
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 1:6758 LAVENDER SKY CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-3647
Mailing Address - Country:US
Mailing Address - Phone:702-416-4630
Mailing Address - Fax:
Practice Address - Street 1:3215 E CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-4235
Practice Address - Country:US
Practice Address - Phone:702-649-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1274225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant