Provider Demographics
NPI:1639108293
Name:OTTER, ELIZABETH ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:OTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:MILROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3434 RIVERTOWN POINT CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3076
Mailing Address - Country:US
Mailing Address - Phone:616-257-3344
Mailing Address - Fax:616-457-1491
Practice Address - Street 1:3290 N WELLNESS DR STE 240
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7261
Practice Address - Country:US
Practice Address - Phone:616-395-9379
Practice Address - Fax:616-820-1457
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001490363AM0700X
MI5601004658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical