Provider Demographics
NPI:1285973289
Name:CORN SOTELO, JESUS ANGEL (PA-C)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ANGEL
Last Name:CORN SOTELO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JESUS
Other - Middle Name:ANGEL
Other - Last Name:CORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:6355 S BUFFALO DR FL 3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2133
Practice Address - Country:US
Practice Address - Phone:702-216-3346
Practice Address - Fax:702-671-6883
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1422363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1285973289Medicaid
NVPA1422OtherSTATE LICENSE