Provider Demographics
NPI:1962101279
Name:SOTERAS, JEREMIAH SICAT (PTA)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:SICAT
Last Name:SOTERAS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11180 BROOKE DR APT 41507
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-6723
Mailing Address - Country:US
Mailing Address - Phone:951-234-6546
Mailing Address - Fax:
Practice Address - Street 1:10225 AUSTIN DR STE 204
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91978-1522
Practice Address - Country:US
Practice Address - Phone:619-670-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52280225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant