Organization
PUEBLO MEDICAL IMAGING, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICAH K NIELSEN M.D. (PRESIDENT)
(702) 477-0772
Entity
Organization
Contact information
Practice address
5495 S RAINBOW BLVD STE 101, LAS VEGAS, NV 89118-1872
(702) 228-0031
Mailing address
PO BOX 30077, DEPT 306, SALT LAKE CITY, UT 84130-0077
(702) 228-0031
Taxonomy
Speciality
Code
Description
License number
State
2085N0700X
Neuroradiology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100500056
—
NV
01
—
NV1651
BCBS OF NV
NV
Enumeration date
05/16/2006
Last updated
06/28/2023
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