Provider Demographics
NPI:1932217536
Name:TRESRIOS PATHOLOGY PC
Entity Type:Organization
Organization Name:TRESRIOS PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-327-2930
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-0407
Mailing Address - Country:US
Mailing Address - Phone:505-327-2930
Mailing Address - Fax:505-599-6290
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-327-2930
Practice Address - Fax:505-599-6290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47119Medicaid
NM47119Medicaid