MEDICARE: MR. ALFRED OTERO PA-C, MPAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA 0003636	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801011663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALFRED OTERO PA-C, MPAS

Provider Business Mailing Address
First Line	:	504 SW PACES GLN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32024
Country	:	US
Telephone Number	:	352-672-0184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1465 W US HIGHWAY 90 STE 100
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-6154
Country	:	US
Telephone Number	:	386-755-2268
Fax Number	:	386-243-8448

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	06/12/2020

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