Provider Demographics
NPI:1245628148
Name:OTT, ELIZABETH WHEELER (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WHEELER
Last Name:OTT
Suffix:
Gender:F
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 1:11047 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:EADS
Mailing Address - State:TN
Mailing Address - Zip Code:38028-9804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-922-6758
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant