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Individual
MR. LOREN GLEN OTT
Active
Individual
MR. LOREN GLEN OTT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA16797
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00PA16797
—
CA
01
—
ZZZ13431Z
MEDICARE PTAN
CA
01
—
ZZZ52846Z
BLUE SHIELD
CA
Enumeration date
05/01/2006
Last updated
12/14/2007
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