Provider Demographics
NPI:1609219831
Name:KOTOVA, DINA (FNP)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:KOTOVA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 THE 25 WAY NE STE 400
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5881
Mailing Address - Country:US
Mailing Address - Phone:505-808-3754
Mailing Address - Fax:505-344-1060
Practice Address - Street 1:4320 THE 25 WAY NE STE 400
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5881
Practice Address - Country:US
Practice Address - Phone:505-808-3754
Practice Address - Fax:505-344-1060
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02153363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93374534Medicaid
NM93374534Medicaid