Basic Information
| Provider Information | |||||||||
| NPI: | 1477865145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTT | ||||||||
| FirstName: | JOHNA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1006 NEW MOODY LN | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400319122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022220028 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Practice Location | |||||||||
| Address1: | 2125 STATE ST STE 5 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022220028 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2010 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1562 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100130280 | 05 | KY | MEDICAID |