Healthcare Provider Details

I. General information

NPI: 1275523276
Provider Name (Legal Business Name): TODD M OTSTOT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E ELM ST
CALDWELL ID
83605-4815
US

IV. Provider business mailing address

206 E ELM ST
CALDWELL ID
83605-4815
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-4511
  • Fax:
Mailing address:
  • Phone: 208-459-4511
  • Fax: 208-459-6602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-356
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA356
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-356
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: