Healthcare Provider Details

I. General information

NPI: 1972601102
Provider Name (Legal Business Name): KERRI S OTTO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KERRI S PETERS PA

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 STEPHANIE LN STE 100
LINCOLN NE
68516-5332
US

IV. Provider business mailing address

PO BOX 6068
LINCOLN NE
68506-0068
US

V. Phone/Fax

Practice location:
  • Phone: 402-484-9009
  • Fax: 402-483-4223
Mailing address:
  • Phone: 402-484-9009
  • Fax: 402-483-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number1020
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number1020
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1020
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: