Healthcare Provider Details

I. General information

NPI: 1104909688
Provider Name (Legal Business Name): OTIS D WRIGHT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7005 MIRA LOMA LN SUITE 102
AUSTIN TX
78723-1411
US

IV. Provider business mailing address

7005 MIRA LOMA LN SUITE 102
AUSTIN TX
78723-1411
US

V. Phone/Fax

Practice location:
  • Phone: 512-795-4344
  • Fax: 512-928-9466
Mailing address:
  • Phone: 512-795-4344
  • Fax: 512-928-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP 16852
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP115175
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: