Provider Demographics
NPI:1790130292
Name:OTIENO, PAULINE
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:
Last Name:OTIENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17855 PARK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-3509
Mailing Address - Country:US
Mailing Address - Phone:512-507-8075
Mailing Address - Fax:512-246-0995
Practice Address - Street 1:3901A SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE 202
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8723
Practice Address - Country:US
Practice Address - Phone:737-226-6700
Practice Address - Fax:737-226-6777
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130845363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily