Provider Demographics
NPI:1023728581
Name:OTERO GOLLARZA, JOSE RAFAEL (RNFA)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:RAFAEL
Last Name:OTERO GOLLARZA
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5281 RIVER GLEN DR UNIT 225
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-8756
Mailing Address - Country:US
Mailing Address - Phone:702-936-2635
Mailing Address - Fax:
Practice Address - Street 1:5281 RIVER GLEN DR UNIT 225
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-8756
Practice Address - Country:US
Practice Address - Phone:702-936-2635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-24
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV22-122246ZC0007X
FLRN9614513163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant