Healthcare Provider Details

I. General information

NPI: 1295706620
Provider Name (Legal Business Name): NICHOLAS CARL BOETTICHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 TOWN CENTRE DR
EAGAN MN
55123-1187
US

IV. Provider business mailing address

PO BOX 14909
MINNEAPOLIS MN
55414-0909
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1145
  • Fax: 612-870-5491
Mailing address:
  • Phone: 612-871-1145
  • Fax: 612-870-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number46944
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: