Provider Demographics
NPI:1073274528
Name:OTTOLINI, JONATHON ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHON
Middle Name:ANDREW
Last Name:OTTOLINI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:37000 GRAND RIVER AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2868
Mailing Address - Country:US
Mailing Address - Phone:248-536-2127
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601010788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant