Provider Demographics
NPI:1922564251
Name:GONZALEZ SOTO, JAVIERA PAZ (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JAVIERA
Middle Name:PAZ
Last Name:GONZALEZ SOTO
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 NELSON RD
Mailing Address - Street 2:APT. 1423
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:865-279-6536
Mailing Address - Fax:
Practice Address - Street 1:4205 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4511
Practice Address - Country:US
Practice Address - Phone:865-279-6536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3209122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
P03669638OtherATHLETIC TRAINER