=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043773955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA OTAH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2019
-----------------------------------------------------
Last Update Date | 07/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9835 N LAKE CREEK PKWY
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78717-6210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-229-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 MOCKINGBIRD HILL CT
-----------------------------------------------------
City | MURPHY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75094-3255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 186224
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number | 186224
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------