Provider Demographics
NPI:1306875604
Name:OTTINGER, WANDA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:JEAN
Last Name:OTTINGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-8828
Mailing Address - Country:US
Mailing Address - Phone:231-652-1522
Mailing Address - Fax:
Practice Address - Street 1:525 4TH ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-9518
Practice Address - Country:US
Practice Address - Phone:231-745-3116
Practice Address - Fax:231-745-3136
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003581OtherSTATE LIC