Healthcare Provider Details

I. General information

NPI: 1720088446
Provider Name (Legal Business Name): JUDITH A BOTTGER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 HAMILTON BLVD
SIOUX CITY IA
51104-1140
US

IV. Provider business mailing address

400 E 10TH ST
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 712-239-3937
  • Fax:
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD042389
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: