Provider Demographics
NPI:1669862629
Name:OTTO, NATHANIEL (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4315
Mailing Address - Country:US
Mailing Address - Phone:253-564-8100
Mailing Address - Fax:
Practice Address - Street 1:4114 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4315
Practice Address - Country:US
Practice Address - Phone:253-564-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60446569111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor