Provider Demographics
NPI:1619452075
Name:OTIS, SAMUEL PATRICK FAUNILLAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL PATRICK
Middle Name:FAUNILLAN
Last Name:OTIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:FAUNILLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2287367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered