Healthcare Provider Details

I. General information

NPI: 1093659484
Provider Name (Legal Business Name): PAYTON A WOTHE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 23RD AVE S STE 400
FARGO ND
58104-8783
US

IV. Provider business mailing address

1502 BELSLY BLVD APT 210
MOORHEAD MN
56560-5197
US

V. Phone/Fax

Practice location:
  • Phone: 701-347-1782
  • Fax: 701-404-8274
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: