Individual
TODD A RADIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
888 S RANCHO DR, LAS VEGAS, NV 89106-3810
(702) 877-8600
Mailing address
PO BOX 15645, LAS VEGAS, NV 89114-5645
(702) 877-8600
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA-C57
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1497757181
SMA MEDICAID
NV
01
—
V110823
SMA MEDICARE
NV
Enumeration date
08/11/2005
Last updated
07/27/2015
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