Provider Demographics
NPI:1003495912
Name:BOTELLO, BRYAN (NP)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BOTELLO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 N MESA ST STE A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1124
Mailing Address - Country:US
Mailing Address - Phone:915-532-2477
Mailing Address - Fax:
Practice Address - Street 1:4305 N MESA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1123
Practice Address - Country:US
Practice Address - Phone:915-532-2477
Practice Address - Fax:915-242-6461
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1034153363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care