Provider Demographics
NPI:1275523276
Name:OTSTOT, TODD M (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:OTSTOT
Suffix:
Gender:M
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 1:206 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4815
Mailing Address - Country:US
Mailing Address - Phone:208-459-4511
Mailing Address - Fax:208-459-6602
Practice Address - Street 1:206 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4815
Practice Address - Country:US
Practice Address - Phone:208-459-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-356363A00000X, 363AM0700X
IDPA356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010035293OtherBLUE SHIELD
ID970022197OtherRAILROAD MEDICARE
ID806153700Medicaid
ID000010035292OtherBLUE SHIELD
IDPAA02OtherBLUE CROSS
IDPAAE9OtherBLUE CROSS
IDPAAE9OtherBLUE CROSS
ID806153700Medicaid