Provider Demographics
NPI:1811527161
Name:SOTO, DEMIZEL
Entity type:Individual
Prefix:
First Name:DEMIZEL
Middle Name:
Last Name:SOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:GRULLA
Mailing Address - State:TX
Mailing Address - Zip Code:78548-0420
Mailing Address - Country:US
Mailing Address - Phone:956-257-5757
Mailing Address - Fax:
Practice Address - Street 1:110 E SAVANNAH AVE STE 203
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1241
Practice Address - Country:US
Practice Address - Phone:956-686-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144754363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX407940201Medicaid