Basic Information
| Provider Information | |||||||||
| NPI: | 1639771819 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SOTO | ||||||||
| FirstName: | OMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 EXECUTIVE BLVD | ||||||||
| Address2: | #148 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152131289 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3710 SAVANNAH AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799305218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158385205 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2020 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 1016566 | TX | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.