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General NPI Number Information
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NPI Number | 1588674865
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Entity Type | Individual
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Provider Name | BERNARD THEODORE BOTILLER PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/09/2006
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Last Update Date | 05/24/2016
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Provider Practice Location Address
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Address Line | 1451 HARRODSBURG ROAD SUITE D 304
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City | LEXINGTON
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State | KY
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Zip | 40504
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Country | UM
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Telephone | 859-977-4000
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Fax | 859-977-5100
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Provider Business Mailing Address
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Address Line | 6400 DUTCHMANS PKWY SUITE 250
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City | LOUISVILLE
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State | KY
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Zip | 40205-3340
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Country | US
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Telephone | 502-587-9660
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Fax | 502-540-5615
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA674
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA674
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License Number State | KY
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