Provider Demographics
NPI:1154193639
Name:OTTERNESS, PHILLIP MARTIN
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MARTIN
Last Name:OTTERNESS
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 1:3152 23RD AVE S APT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-5573
Mailing Address - Country:US
Mailing Address - Phone:612-321-8008
Mailing Address - Fax:
Practice Address - Street 1:3152 23RD AVE S APT 2
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-5573
Practice Address - Country:US
Practice Address - Phone:612-321-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management