Healthcare Provider Details

I. General information

NPI: 1932217536
Provider Name (Legal Business Name): TRESRIOS PATHOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE ST
FARMINGTON NM
87401-5630
US

IV. Provider business mailing address

PO BOX 407
FARMINGTON NM
87499-0407
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-2930
  • Fax: 505-599-6290
Mailing address:
  • Phone: 505-327-2930
  • Fax: 505-599-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT OTTESON
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 505-327-2930