Provider Demographics
NPI:1558817833
Name:KOTERWSKI, CARL (LAT ATC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:KOTERWSKI
Suffix:
Gender:M
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8203 VISTA COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-4312
Mailing Address - Country:US
Mailing Address - Phone:702-289-1246
Mailing Address - Fax:
Practice Address - Street 1:8203 VISTA COLORADO ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-4312
Practice Address - Country:US
Practice Address - Phone:702-289-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0506379390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program