Provider Demographics
NPI:1811537483
Name:OTTO, WESLEY D (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:D
Last Name:OTTO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12115 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-5509
Mailing Address - Country:US
Mailing Address - Phone:806-531-3977
Mailing Address - Fax:
Practice Address - Street 1:12115 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-5509
Practice Address - Country:US
Practice Address - Phone:806-745-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80926237700000X
TX1108427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist