Provider Demographics
NPI:1093236267
Name:OTTEM LILL, AGATHA J (PA-C)
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:J
Last Name:OTTEM LILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AGATHA
Other - Middle Name:J
Other - Last Name:OTTEM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4183
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:4440 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7245
Practice Address - Country:US
Practice Address - Phone:701-732-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant