Provider Demographics
NPI:1447595475
Name:OTTE, MELISSA (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:OTTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 FOUNDRY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5421
Mailing Address - Country:US
Mailing Address - Phone:603-230-5645
Mailing Address - Fax:603-227-7584
Practice Address - Street 1:18 FOUNDRY ST STE 102
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5421
Practice Address - Country:US
Practice Address - Phone:603-230-5645
Practice Address - Fax:603-227-7584
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016261363A00000X
NH0977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03576501Medicaid
NYJ400082817Medicare PIN