Basic Information
| Provider Information | |||||||||
| NPI: | 1275620155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTNICK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOTNICK | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | MARC | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | STE 210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035848000 | ||||||||
| FaxNumber: | 3035848141 | ||||||||
| Practice Location | |||||||||
| Address1: | 9195 GRANT STREET #120 | ||||||||
| Address2: | NORTH DENVER ORTHOPEDIC SPECIALISTS | ||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802294386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034532997 | ||||||||
| FaxNumber: | 3034532998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 44 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07440001 | 05 | CO | MEDICAID |