Provider Demographics
NPI:1720227846
Name:JIRAU SOTO, EDGARDO J
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:J
Last Name:JIRAU 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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:ANGELES
Mailing Address - State:PR
Mailing Address - Zip Code:00611-0099
Mailing Address - Country:US
Mailing Address - Phone:787-933-6781
Mailing Address - Fax:787-933-6781
Practice Address - Street 1:CARR 111 INT 602 KM 0.1
Practice Address - Street 2:
Practice Address - City:ANGELES
Practice Address - State:PR
Practice Address - Zip Code:00611-0000
Practice Address - Country:US
Practice Address - Phone:787-933-6781
Practice Address - Fax:787-933-6781
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC AMB 559341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRTC AMB 559OtherLIC COMICION