Provider Demographics
NPI:1912390253
Name:OETKEN, CAITLIN C (PA-C)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:C
Last Name:OETKEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:LEIGH
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 HERITAGE TRACE PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-8905
Mailing Address - Country:US
Mailing Address - Phone:817-431-7985
Mailing Address - Fax:
Practice Address - Street 1:4601 HERITAGE TRACE PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8905
Practice Address - Country:US
Practice Address - Phone:817-431-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108543363AM0700X
TXPA12191363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014517600Medicaid
FLIC674ZOtherMCR
FLY0R0QOtherBCBS