Healthcare Provider Details

I. General information

NPI: 1093726648
Provider Name (Legal Business Name): ANDREW T OTTO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR STE C100
GREENVILLE SC
29615-6322
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-7422
  • Fax:
Mailing address:
  • Phone: 864-797-6328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number843
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: