Healthcare Provider Details

I. General information

NPI: 1053428177
Provider Name (Legal Business Name): BONNIE KAYE OTTO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OV SHOPPING CENTER SUITE 2A
LEETSDALE PA
15056
US

IV. Provider business mailing address

305 TIMBER LN
SEWICKLEY PA
15143-8952
US

V. Phone/Fax

Practice location:
  • Phone: 412-741-2700
  • Fax: 412-741-9766
Mailing address:
  • Phone: 412-749-9694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052252
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: