Provider Demographics
NPI:1558697177
Name:OTTO, JASON L (MPAS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:L
Last Name:OTTO
Suffix:
Gender:M
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 W 5TH ST, STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2705
Mailing Address - Country:US
Mailing Address - Phone:307-675-2650
Mailing Address - Fax:307-675-2651
Practice Address - Street 1:1333 W 5TH ST, STE 112
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2752
Practice Address - Country:US
Practice Address - Phone:307-675-2650
Practice Address - Fax:307-675-2651
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical