Provider Demographics
NPI:1548227291
Name:OTT, ERNEST (CRNA)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:OTT
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 1:2011 JAMESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9193
Mailing Address - Country:US
Mailing Address - Phone:870-932-4448
Mailing Address - Fax:
Practice Address - Street 1:2011 JAMESTOWN DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9193
Practice Address - Country:US
Practice Address - Phone:870-932-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00821367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121757701Medicaid
AR59928Medicare ID - Type Unspecified