Provider Demographics
NPI:1245911262
Name:OTIS, JUSTIN A (DNP, APRN-CRNA)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:A
Last Name:OTIS
Suffix:
Gender:M
Credentials:DNP, APRN-CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 JUDGE CARDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-7805
Mailing Address - Country:US
Mailing Address - Phone:904-240-2841
Mailing Address - Fax:
Practice Address - Street 1:11723 WELLS CREEK PKWY APT 1217
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1981
Practice Address - Country:US
Practice Address - Phone:904-240-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9356204163W00000X
KY4012118367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse