Provider Demographics
NPI:1174509541
Name:BOETTGER, PETER (PA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:BOETTGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:252-744-3253
Mailing Address - Fax:252-744-3194
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:LEO JENKINS CANCER CENTER
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-744-2383
Practice Address - Fax:252-744-3565
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC100862363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC970005706OtherRAILROAD MEDICARE
NC970005706OtherRAILROAD MEDICARE
NCS55570Medicare UPIN