Healthcare Provider Details

I. General information

NPI: 1922198985
Provider Name (Legal Business Name): HANS BOTZKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13207 RAVENNA RD
CHARDON OH
44024-7032
US

IV. Provider business mailing address

5700 DARROW RD SUITE 106
HUDSON OH
44236-5021
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-6000
  • Fax: 330-656-5901
Mailing address:
  • Phone: 330-656-5911
  • Fax: 330-656-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50001748
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: