Individual
NICHOLAS OTAZO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3RD MRB 20073, CAMP LEJEUNE, NC 28546
(470) 509-0705
Mailing address
1060 HENRYS HL, GREENSBORO, GA 30642-5209
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Enumeration date
08/15/2019
Last updated
08/15/2019
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