Provider Demographics
NPI:1194393918
Name:OETJEN, KACI ALLISON
Entity Type:Individual
Prefix:MISS
First Name:KACI
Middle Name:ALLISON
Last Name:OETJEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 OCONEE CONNECTOR BLDG 300
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7314
Mailing Address - Country:US
Mailing Address - Phone:706-549-8306
Mailing Address - Fax:
Practice Address - Street 1:1357 OCONEE CONNECTOR BLDG 300
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7314
Practice Address - Country:US
Practice Address - Phone:706-549-8306
Practice Address - Fax:706-549-4099
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10703363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical