Healthcare Provider Details

I. General information

NPI: 1881995447
Provider Name (Legal Business Name): ELIZABETH R OTTEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH R PHILLIPS PA-C

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7272
  • Fax: 616-361-5828
Mailing address:
  • Phone: 616-363-7272
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601005945
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005945
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: