Provider Demographics
NPI:1972601102
Name:OTTO, KERRI S (PA)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:S
Last Name:OTTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:S
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 6068
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-0068
Mailing Address - Country:US
Mailing Address - Phone:402-484-9009
Mailing Address - Fax:402-483-4223
Practice Address - Street 1:7100 STEPHANIE LN STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5332
Practice Address - Country:US
Practice Address - Phone:402-484-9009
Practice Address - Fax:402-483-4223
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1020207NP0225X, 207NS0135X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065843713Medicaid
NE098957002Medicare PIN
P55643Medicare UPIN