Provider Demographics
NPI:1699387308
Name:ONTIVEROS, ROBERTO (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 ENCHANTED CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-7508
Mailing Address - Country:US
Mailing Address - Phone:602-618-3545
Mailing Address - Fax:
Practice Address - Street 1:1801 N OREGON ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3524
Practice Address - Country:US
Practice Address - Phone:915-521-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX790864367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse