Provider Demographics
NPI:1255375903
Name:OTERO, CHARLES DANIEL (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DANIEL
Last Name:OTERO
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:701 ARIZONA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2110
Mailing Address - Country:US
Mailing Address - Phone:575-742-3033
Mailing Address - Fax:575-742-1133
Practice Address - Street 1:701 ARIZONA ST
Practice Address - Street 2:SUITE A
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-2110
Practice Address - Country:US
Practice Address - Phone:575-742-3033
Practice Address - Fax:575-742-1133
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM93-PA01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97903Medicaid
R1322Medicare UPIN
NM97903Medicaid