Provider Demographics
NPI:1821541905
Name:OTTEMAN, MARY (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:OTTEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:OBRIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:16910 FRANCES ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2398
Mailing Address - Country:US
Mailing Address - Phone:402-505-8777
Mailing Address - Fax:402-933-7767
Practice Address - Street 1:16910 FRANCES ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2398
Practice Address - Country:US
Practice Address - Phone:402-505-8777
Practice Address - Fax:402-933-7767
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant