Provider Demographics
NPI:1063681302
Name:MARRACCINI-OTTO, CAROL (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MARRACCINI-OTTO
Suffix:
Gender:F
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 1:1850 SULLIVAN AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2221
Mailing Address - Country:US
Mailing Address - Phone:650-756-5630
Mailing Address - Fax:650-756-1964
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2221
Practice Address - Country:US
Practice Address - Phone:650-756-5630
Practice Address - Fax:650-756-1964
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant