Provider Demographics
NPI:1417916040
Name:OTTE, TODD (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:OTTE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 804408
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-4408
Mailing Address - Country:US
Mailing Address - Phone:816-792-7126
Mailing Address - Fax:816-792-7196
Practice Address - Street 1:2525 GLENN HENDREN DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9625
Practice Address - Country:US
Practice Address - Phone:816-781-7200
Practice Address - Fax:816-792-7196
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104599367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO912680303Medicaid
MO912680303Medicaid
MOR30194Medicare UPIN
MO4526807Medicare PIN