Healthcare Provider Details

I. General information

NPI: 1093180432
Provider Name (Legal Business Name): MICHAEL OTTE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 LAKE MURRAY BLVD
LA MESA CA
91942-2502
US

IV. Provider business mailing address

6136 LAKE MURRAY BLVD
LA MESA CA
91942-2502
US

V. Phone/Fax

Practice location:
  • Phone: 714-389-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: