Provider Demographics
NPI:1588133193
Name:SOTO, JASMIN A (GRNA)
Entity type:Individual
Prefix:
First Name:JASMIN
Middle Name:A
Last Name:SOTO
Suffix:
Gender:F
Credentials:GRNA
Other - Prefix:
Other - First Name:JASMIN
Other - Middle Name:GUTIERREZ
Other - Last Name:ADVINCULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GRNA
Mailing Address - Street 1:4040 OBSIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-0465
Mailing Address - Country:US
Mailing Address - Phone:909-782-9102
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000965367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered