Healthcare Provider Details

I. General information

NPI: 1447576970
Provider Name (Legal Business Name): CRISTOBAL RUBEN SOTO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY SUITE 105
SAN DIEGO CA
92102-4500
US

IV. Provider business mailing address

PO BOX 433968
SAN YSIDRO CA
92143-3968
US

V. Phone/Fax

Practice location:
  • Phone: 619-264-1934
  • Fax: 619-264-1937
Mailing address:
  • Phone: 619-409-6900
  • Fax: 619-409-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: