Provider Demographics
NPI:1306182555
Name:OTTE, SONIA V (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SONIA
Middle Name:V
Last Name:OTTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1951 SW 172ND AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-5593
Practice Address - Country:US
Practice Address - Phone:305-606-7028
Practice Address - Fax:954-362-2762
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPAX00009762363A00000X
FLPA9106875363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60280OtherHEALTH SUN HEALTH PLAN
FLQMP000004134117OtherMOLINA HEALTH
FLY0ET0OtherBCBS FL
FL26560OtherMEDICA HEALTH
FL9953918OtherAETNA
FLP01130707OtherRAILROAD MCR
FL26560OtherMEDICA HEALTH
FLGW020ZMedicare PIN