Provider Demographics
NPI:1568913622
Name:OTTO, JEFFREY (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4567
Mailing Address - Country:US
Mailing Address - Phone:763-427-9980
Mailing Address - Fax:
Practice Address - Street 1:2800 CAMPUS DR STE 30
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2669
Practice Address - Country:US
Practice Address - Phone:763-398-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant