Provider Demographics
NPI:1760464119
Name:SOTO-HERNANDEZ, ANTI NELLY (MD)
Entity Type:Individual
Prefix:
First Name:ANTI
Middle Name:NELLY
Last Name:SOTO-HERNANDEZ
Suffix:
Gender:F
Credentials:MD
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4005 HIGH RESORT BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87124-5906
Practice Address - Country:US
Practice Address - Phone:505-462-6000
Practice Address - Fax:505-462-8470
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD20030762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08683Medicare UPIN