Provider Demographics
NPI:1679097976
Name:DETIBERIIS, ALAN (APATH, DNP)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:DETIBERIIS
Suffix:
Gender:M
Credentials:APATH, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 SEMINOLE LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5565
Mailing Address - Country:US
Mailing Address - Phone:702-265-3033
Mailing Address - Fax:
Practice Address - Street 1:1205 W WARM SPRINGS RD STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-8741
Practice Address - Country:US
Practice Address - Phone:702-265-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZD-16-1125-1121-A207ZP0101X
NVNA374K00000X
NV405787207ZC0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0008XAllopathic & Osteopathic PhysiciansPathologyClinical Informatics
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner