MEDICARE: JORGE ENRIQUE DE LA ROTTA SOTO APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11001660	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245791078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE ENRIQUE DE LA ROTTA SOTO APRN

Provider Business Mailing Address
First Line	:	90 FORT WADE RD STE 100
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5114
Country	:	US
Telephone Number	:	904-377-2675
Fax Number	:

Provider Business Practice Location Address
First Line	:	90 FORT WADE RD STE 100
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5114
Country	:	US
Telephone Number	:	904-377-2675
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	12/02/2025

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