Basic Information
| Provider Information | |||||||||
| NPI: | 1831782366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTTEN | ||||||||
| FirstName: | AUSTYN | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKER | ||||||||
| OtherFirstName: | AUSTYN | ||||||||
| OtherMiddleName: | KAY | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 617 NAKOMA DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486402829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168086323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1509 N MCEWAN ST | ||||||||
| Address2: | |||||||||
| City: | CLARE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486171113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893868170 | ||||||||
| FaxNumber: | 9893868175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2021 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704254199 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.