Provider Demographics
NPI:1649674433
Name:GAYTAN, IRMA EDITH (OTR)
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:EDITH
Last Name:GAYTAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 LOMA AZUL
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-3373
Mailing Address - Country:US
Mailing Address - Phone:956-451-4210
Mailing Address - Fax:
Practice Address - Street 1:4716 S JACKSON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6199
Practice Address - Country:US
Practice Address - Phone:956-618-1300
Practice Address - Fax:956-618-1385
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist