Provider Demographics
NPI:1124328729
Name:OTT, ASHLEY (PA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:OTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:614 PLEASURE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-4925
Mailing Address - Country:US
Mailing Address - Phone:631-697-4347
Mailing Address - Fax:
Practice Address - Street 1:33 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11959-4000
Practice Address - Country:US
Practice Address - Phone:631-653-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1096087207Q00000X
NY014441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMC2384357OtherDEA