Provider Demographics
NPI:1639771819
Name:SOTO, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:SOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 EXECUTIVE BLVD
Mailing Address - Street 2:#148
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-213-1289
Mailing Address - Fax:
Practice Address - Street 1:3710 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-5218
Practice Address - Country:US
Practice Address - Phone:915-838-5205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1016566164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse