Provider Demographics
NPI:1538582283
Name:OTIS, MARIBETH ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MARIBETH
Middle Name:ANNE
Last Name:OTIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIBETH
Other - Middle Name:ANNE
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4069 LAKE DR SE STE 118
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-267-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant