Provider Demographics
NPI:1699861732
Name:OTTERSBACH, GARY M (PA-C)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:OTTERSBACH
Suffix:
Gender:M
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 1:2521 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4126
Mailing Address - Country:US
Mailing Address - Phone:307-472-2293
Mailing Address - Fax:
Practice Address - Street 1:2521 E 15TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4126
Practice Address - Country:US
Practice Address - Phone:307-472-2293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1001363A00000X
WY115363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
V102939Medicare PIN
R04485Medicare UPIN