Healthcare Provider Details

I. General information

NPI: 1457014821
Provider Name (Legal Business Name): LUIS DAVID RIVERA SOTO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/11/2025
Certification Date: 10/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COFFMAN ST
LONGMONT CO
80501-5918
US

IV. Provider business mailing address

201 COFFMAN ST
LONGMONT CO
80501-5918
US

V. Phone/Fax

Practice location:
  • Phone: 720-577-5251
  • Fax: 720-780-7057
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9115235
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: