Provider Demographics
NPI:1699738302
Name:KOTARA, STANLEY J (PA)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:J
Last Name:KOTARA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1122
Mailing Address - Country:US
Mailing Address - Phone:806-792-4329
Mailing Address - Fax:806-792-9466
Practice Address - Street 1:4110 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1122
Practice Address - Country:US
Practice Address - Phone:806-792-4329
Practice Address - Fax:806-792-9466
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y8601OtherBLUE CROSS
TX8Y8601OtherBLUE CROSS