MEDICARE: SARAH TERESA BOT PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant	10018	MN
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	10018	MN

General Provider Information

NPI Number	:	1699701672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH TERESA BOT PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	6525 FRANCE AVE SOUTH
Second Line	:	SUITE 100
City	:	EDINA
State	:	MN
Zip	:	55435-3624
Country	:	US
Telephone Number	:	952-927-4021
Fax Number	:	952-927-4026

Provider Business Practice Location Address
First Line	:	6525 FRANCE AVE SOUTH
Second Line	:	SUITE 100
City	:	EDINA
State	:	MN
Zip	:	55435-3624
Country	:	US
Telephone Number	:	932-927-4021
Fax Number	:	952-927-4026

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	10/11/2007

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