Basic Information
| Provider Information | |||||||||
| NPI: | 1992121156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTTA | ||||||||
| FirstName: | VINCENT | ||||||||
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| Credential: | A.P.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2340 S EOLA RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605036410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306925190 | ||||||||
| FaxNumber: | 6306925185 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 N EOLA RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605029619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306925660 | ||||||||
| FaxNumber: | 6306925661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209011348 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 277001993 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.