Provider Demographics
NPI:1053428177
Name:OTTO, BONNIE KAYE (PA-C)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:KAYE
Last Name:OTTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-8952
Mailing Address - Country:US
Mailing Address - Phone:412-749-9694
Mailing Address - Fax:
Practice Address - Street 1:OV SHOPPING CENTER
Practice Address - Street 2:SUITE 2A
Practice Address - City:LEETSDALE
Practice Address - State:PA
Practice Address - Zip Code:15056
Practice Address - Country:US
Practice Address - Phone:412-741-2700
Practice Address - Fax:412-741-9766
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant