Provider Demographics
NPI:1811000243
Name:OTT, EUGENE E (PA-C)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:E
Last Name:OTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SHERMAN AVE E
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1960
Mailing Address - Country:US
Mailing Address - Phone:920-568-5000
Mailing Address - Fax:
Practice Address - Street 1:611 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI293-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42945400Medicaid
WI42945400Medicaid