=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609219831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DINA KOTOVA FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2013
-----------------------------------------------------
Last Update Date | 02/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4320 THE 25 WAY NE STE 400
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-5881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-808-3754
-----------------------------------------------------
Fax | 505-344-1060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4320 THE 25 WAY NE STE 400
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-5881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-808-3754
-----------------------------------------------------
Fax | 505-344-1060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP-02153
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CNP-02153
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------