Healthcare Provider Details

I. General information

NPI: 1013517978
Provider Name (Legal Business Name): JENNIFER LYNN OTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 RUTLEDGE RD NE
ALBUQUERQUE NM
87109-5566
US

IV. Provider business mailing address

9200 LONA LN NE
ALBUQUERQUE NM
87111-1619
US

V. Phone/Fax

Practice location:
  • Phone: 505-798-9300
  • Fax: 505-798-0808
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: