Provider Demographics
NPI:1114763844
Name:OTT, WADE
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:OTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 S 153RD CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5114
Mailing Address - Country:US
Mailing Address - Phone:402-983-2776
Mailing Address - Fax:
Practice Address - Street 1:649 S 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-1002
Practice Address - Country:US
Practice Address - Phone:402-983-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program