Healthcare Provider Details

I. General information

NPI: 1699347732
Provider Name (Legal Business Name): MARIMAR OTERO-ROJAS AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

4147 S 800 W
RIVERDALE UT
84405-2803
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-644-5354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number9643798-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: