Healthcare Provider Details

I. General information

NPI: 1386838407
Provider Name (Legal Business Name): OTIS PERRY MAX INGERSOLL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: OTIS PERRY MAX INGERSOLL FNP

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SAN PABLO AVE
ALBANY CA
94706-1103
US

IV. Provider business mailing address

500 SAN PABLO AVE
ALBANY CA
94706-1103
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-8130
  • Fax: 510-524-0861
Mailing address:
  • Phone: 510-204-8130
  • Fax: 510-524-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: