NPIMap

Organization Active NPI

Good Samaritan Family Practice

  • Family Nurse Practitioner
  • Las Vegas, NV
National Provider Identifier
1366802159
Registry record updated Mar 7, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
APRN002072 Issued in NV
Legal business name
GOOD SAMARITAN FAMILY PRACTICE
Practice address
4220 Saxton Green Avenue
Las Vegas, NV 89141
Phone
(702) 400-0517
NPI assigned
Mar 7, 2016
Last updated
Mar 7, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Stanley M Kidiavayi, APRNNPI 1902290968
Title
Nurse Practictioner
Phone
(702) 400-0517

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LF0000X APRN002072 NV Primary

Addresses

Primary practice location

4220 Saxton Green Avenue
Las Vegas, NV 89141

Mailing address

4220 Saxton Green Ave
Las Vegas, NV 89141-4354
Phone (702) 400-0517

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NV, AZ, CA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20160802001897 NV Part B Supplier - Clinic/Group Practice 2365736196 Receives reassigned benefits from 12 practitioners
Practice locations: Las Vegas, NV
O20231114000755 AZ Part B Supplier - Clinic/Group Practice 2365736196 Receives reassigned benefits from 2 practitioners
Practice locations: Phoenix, AZ
O20241220000978 CA Part B Supplier - Clinic/Group Practice 2365736196 Receives reassigned benefits from 1 practitioner
Practice locations: San Diego, CA

National Provider Directory

National Provider Directory

Locations

5482 Complex St
Ste 113
San Diego, CA 92123
Phone (702) 400-0517

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1457308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1457308800000",
    "number": "1366802159",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4220 SAXTON GREEN AVE",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891414354",
            "telephone_number": "702-400-0517"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4220 SAXTON GREEN AVENUE",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "89141",
            "telephone_number": "702-400-0517"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GOOD SAMARITAN FAMILY PRACTICE",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-07",
        "last_updated": "2016-03-07",
        "status": "A",
        "authorized_official_last_name": "KIDIAVAYI",
        "authorized_official_first_name": "STANLEY",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "NURSE PRACTICTIONER",
        "authorized_official_telephone_number": "702-400-0517",
        "authorized_official_credential": "APRN"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "NV",
            "license": "APRN002072",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Las Vegas, NV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.