Provider Demographics
NPI:1003879867
Name:OTERO, KRISTIN N (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:N
Last Name:OTERO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-877-5350
Mailing Address - Fax:414-877-5360
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:414-447-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1629-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIQ14125Medicare UPIN
WI002201710Medicare ID - Type Unspecified