Healthcare Provider Details

I. General information

NPI: 1255375903
Provider Name (Legal Business Name): CHARLES DANIEL OTERO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 ARIZONA ST SUITE A
CLOVIS NM
88101-2110
US

IV. Provider business mailing address

701 ARIZONA ST SUITE A
CLOVIS NM
88101-2110
US

V. Phone/Fax

Practice location:
  • Phone: 575-742-3033
  • Fax: 575-742-1133
Mailing address:
  • Phone: 575-742-3033
  • Fax: 575-742-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number93-PA01
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: