=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639108293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH ANN OTTER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 09/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3290 N WELLNESS DR STE 240
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49424-7261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-395-9379
-----------------------------------------------------
Fax | 616-820-1457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3434 RIVERTOWN POINT CT SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-257-3344
-----------------------------------------------------
Fax | 616-457-1491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA0000001490
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601004658
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------