Provider Demographics
NPI:1669240701
Name:OTTESEN, ERIC MAGNUS (RN)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:MAGNUS
Last Name:OTTESEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 NE HIGHWAY 20 STE 610
Mailing Address - Street 2:#524
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3350 NE MANCHESTER CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-8360
Practice Address - Country:US
Practice Address - Phone:458-206-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200441057RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse