MEDICARE: LILAC BOTBOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP122327	TX

General Provider Information

NPI Number	:	1215286919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILAC BOTBOL

Provider Business Mailing Address
First Line	:	1606 GAYLORD DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78728-5712
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1606 GAYLORD DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78728-5712
Country	:	US
Telephone Number	:	512-965-9120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2012
Last Update Date	:	08/19/2022

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Directions to “ LILAC BOTBOL ” Practice Location

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