Provider Demographics
NPI:1386838407
Name:INGERSOLL, OTIS PERRY MAX (FNP)
Entity Type:Individual
Prefix:
First Name:OTIS PERRY
Middle Name:MAX
Last Name:INGERSOLL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:OTIS
Other - Middle Name:PERRY MAX
Other - Last Name:INGERSOLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:500 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1103
Mailing Address - Country:US
Mailing Address - Phone:510-204-8130
Mailing Address - Fax:510-524-0861
Practice Address - Street 1:500 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1103
Practice Address - Country:US
Practice Address - Phone:510-204-8130
Practice Address - Fax:510-524-0861
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily