Provider Demographics
NPI:1912783598
Name:OTTESON, TAMARA GLEE (PTA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:GLEE
Last Name:OTTESON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21109 HONEYCOMB WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6401
Mailing Address - Country:US
Mailing Address - Phone:612-308-2349
Mailing Address - Fax:
Practice Address - Street 1:14650 GARRETT AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7543
Practice Address - Country:US
Practice Address - Phone:952-236-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA965225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant