Healthcare Provider Details

I. General information

NPI: 1023728581
Provider Name (Legal Business Name): JOSE RAFAEL OTERO GOLLARZA RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5281 RIVER GLEN DR UNIT 225
LAS VEGAS NV
89103-8756
US

IV. Provider business mailing address

5281 RIVER GLEN DR UNIT 225
LAS VEGAS NV
89103-8756
US

V. Phone/Fax

Practice location:
  • Phone: 702-936-2635
  • Fax:
Mailing address:
  • Phone: 702-936-2635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number22-122
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN9614513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: