Provider Demographics
NPI:1174845226
Name:OTTO, RYAN DAVID (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:OTTO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:275 W MACARTHUR BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5641
Mailing Address - Country:US
Mailing Address - Phone:650-823-9384
Mailing Address - Fax:
Practice Address - Street 1:275 W MACARTHUR BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5641
Practice Address - Country:US
Practice Address - Phone:510-752-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA20845363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant