Provider Demographics
NPI:1316904428
Name:OTT, LOREN GLEN (PA)
Entity type:Individual
Prefix:MR
First Name:LOREN
Middle Name:GLEN
Last Name:OTT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ESPLANADE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3369
Mailing Address - Country:US
Mailing Address - Phone:530-897-4500
Mailing Address - Fax:530-897-4544
Practice Address - Street 1:1600 ESPLANADE
Practice Address - Street 2:SUITE C
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3369
Practice Address - Country:US
Practice Address - Phone:530-897-4500
Practice Address - Fax:530-897-4544
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13431ZOtherMEDICARE PTAN
CA00PA16797Medicaid
CAZZZ52846ZOtherBLUE SHIELD
P96722Medicare UPIN
CA00PA16797Medicaid