MEDICARE: OTIS D WRIGHT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	NP 16852	CA
2	363LG0600X	Gerontology Nurse Practitioner	AP115175	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AP115175	OTHER	TX	NP LICENSE
2	NP16852	OTHER	CA	NP LICENSE

General Provider Information

NPI Number	:	1104909688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OTIS D WRIGHT NP

Provider Business Mailing Address
First Line	:	7005 MIRA LOMA LN
Second Line	:	SUITE 102
City	:	AUSTIN
State	:	TX
Zip	:	78723-1411
Country	:	US
Telephone Number	:	512-795-4344
Fax Number	:	512-928-9466

Provider Business Practice Location Address
First Line	:	7005 MIRA LOMA LN
Second Line	:	SUITE 102
City	:	AUSTIN
State	:	TX
Zip	:	78723-1411
Country	:	US
Telephone Number	:	512-795-4344
Fax Number	:	512-928-9466

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	01/31/2017

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