Healthcare Provider Details

I. General information

NPI: 1194460089
Provider Name (Legal Business Name): JAVIER URTEAGA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 MEADOWLARK ST
SHAW AFB SC
29152-5019
US

IV. Provider business mailing address

1638 ELSIE JEAN TRAIL
CHEYENNE WY
82007
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-2273
  • Fax:
Mailing address:
  • Phone: 951-212-7135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: