Basic Information
| Provider Information | |||||||||
| NPI: | 1992034458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OETTING | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914000 | ||||||||
| FaxNumber: | 4198748657 | ||||||||
| Practice Location | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914000 | ||||||||
| FaxNumber: | 4198748657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2009 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704185806 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | COA 17191 NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | MI4068021 | 01 | MI | MEDICARE | OTHER | H429260 | 01 | OH | MEDICARE PIN | OTHER | 0129568 | 05 | OH | MEDICAID | 1992034458 | 05 | MI | MEDICAID |