Provider Demographics
NPI:1982030987
Name:OTTESON, PAUL EIRIK (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:EIRIK
Last Name:OTTESON
Suffix:
Gender:
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:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9223
Practice Address - Street 1:825 NE GATEWAY DR STE 148
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-1307
Practice Address - Country:US
Practice Address - Phone:515-875-9607
Practice Address - Fax:515-875-9608
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13358363A00000X
NC0010-04519363A00000X
IA082773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-04519OtherNORTH CAROLINA PA LICENSE