MEDICARE: OTTO PENALVER PACHECO APRN CNP

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	1023204	TX

General Provider Information

NPI Number	:	1902644545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OTTO PENALVER PACHECO APRN CNP

Provider Business Mailing Address
First Line	:	21023 BELMONT VILLAGE WAY
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-3193
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23217 RED RIVER DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-2031
Country	:	US
Telephone Number	:	832-913-3262
Fax Number	:

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

Provider Enumeration Date	:	07/17/2024
Last Update Date	:	07/17/2024

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