Healthcare Provider Details

I. General information

NPI: 1689352767
Provider Name (Legal Business Name): ORESTES ROMAN ORTEGA NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 E BASELINE RD STE 105
MESA AZ
85204-7290
US

IV. Provider business mailing address

2031 W DIXON ST
MESA AZ
85201-4416
US

V. Phone/Fax

Practice location:
  • Phone: 480-497-5933
  • Fax: 480-497-5934
Mailing address:
  • Phone: 602-481-7286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTEMP245660
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number245660
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: