Provider Demographics
NPI:1982051850
Name:OTTO, CHRIS (PA)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3236 E GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5100
Mailing Address - Country:US
Mailing Address - Phone:307-760-8602
Mailing Address - Fax:307-460-9880
Practice Address - Street 1:3236 E GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5100
Practice Address - Country:US
Practice Address - Phone:307-760-8602
Practice Address - Fax:307-460-9880
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA734363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical