Provider Demographics
NPI:1245791078
Name:DE LA ROTTA SOTO, JORGE ENRIQUE (APRN)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ENRIQUE
Last Name:DE LA ROTTA SOTO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 FORT WADE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-5114
Mailing Address - Country:US
Mailing Address - Phone:904-377-2675
Mailing Address - Fax:
Practice Address - Street 1:90 FORT WADE RD STE 100
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5114
Practice Address - Country:US
Practice Address - Phone:904-377-2675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily