Provider Demographics
NPI:1801011663
Name:OTERO, ALFRED (PA-C, MPAS)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:
Last Name:OTERO
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 SW PACES GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024
Mailing Address - Country:US
Mailing Address - Phone:352-672-0184
Mailing Address - Fax:
Practice Address - Street 1:1465 W US HIGHWAY 90 STE 100
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-6154
Practice Address - Country:US
Practice Address - Phone:386-755-2268
Practice Address - Fax:386-243-8448
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 0003636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291002100Medicaid
FLE 3453 ZMedicare ID - Type Unspecified
FLS 95454Medicare UPIN