Provider Demographics
NPI:1861595399
Name:MORTEL, AGNES P (MD)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:P
Last Name:MORTEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 ALTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107
Mailing Address - Country:US
Mailing Address - Phone:702-822-2607
Mailing Address - Fax:702-822-2656
Practice Address - Street 1:5025 ALTA DRIVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107
Practice Address - Country:US
Practice Address - Phone:702-822-2607
Practice Address - Fax:702-822-2656
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV7530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018249Medicaid
G12966Medicare UPIN
NVV34872Medicare ID - Type Unspecified