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General NPI Number Information
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NPI Number | 1811583446
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Entity Type | Individual
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Provider Name | STEFAN BOTHA
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Gender | Male
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Dates
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Enumeration Date | 12/17/2020
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Last Update Date | 01/15/2025
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Provider Practice Location Address
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Address Line | 3301 W GANDY BLVD
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City | TAMPA
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State | FL
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Zip | 33611-2931
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Country | US
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Telephone | 813-925-1903
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Fax | 813-749-8370
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Provider Business Mailing Address
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Address Line | 4909 TUCUMCARI TRL
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City | SARASOTA
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State | FL
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Zip | 34241-9118
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Country | US
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Telephone | 210-264-4348
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Fax |
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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 | PA14092
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9119631
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License Number State | FL
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