Provider Demographics
NPI:1700838323
Name:OTTEN, PATRICK (PT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:OTTEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:3720 QUEEN CT SW
Practice Address - Street 2:STE I
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-4735
Practice Address - Country:US
Practice Address - Phone:319-364-0300
Practice Address - Fax:319-364-4043
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1721225100000X
IA03532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506475Medicaid
IAIB1212041Medicare PIN
IAIB1213Medicare PIN
IAIB1213040Medicare PIN
NV100506475Medicaid