Provider Demographics
NPI: | 1134325012 |
---|---|
Name: | BOETTCHER, ADAM KEITH (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ADAM |
Middle Name: | KEITH |
Last Name: | BOETTCHER |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1020 N SAN FRANCISCO ST STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | FLAGSTAFF |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 86001-3281 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 928-774-2300 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1020 N SAN FRANCISCO ST STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | FLAGSTAFF |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 86001-3281 |
Practice Address - Country: | US |
Practice Address - Phone: | 928-774-2300 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-06-26 |
Last Update Date: | 2020-01-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 45896 | 2086S0122X |
MI | 4301090356 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | P707631 | Medicaid |