Provider Demographics
NPI:1770365884
Name:OTTO, TYLER JAMES
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:OTTO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11953 FERMAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:MAPLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55358-6030
Mailing Address - Country:US
Mailing Address - Phone:612-816-9003
Mailing Address - Fax:
Practice Address - Street 1:2507 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-4516
Practice Address - Country:US
Practice Address - Phone:612-816-9003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program