Healthcare Provider Details

I. General information

NPI: 1538354097
Provider Name (Legal Business Name): CARLOS HUMBERTO SOTO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 6600
ALBUQUERQUE NM
87106-5411
US

IV. Provider business mailing address

201 CEDAR ST SE STE 6600
ALBUQUERQUE NM
87106-5411
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-3208
  • Fax: 505-724-4384
Mailing address:
  • Phone: 505-724-3208
  • Fax: 505-724-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2013-0035
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: