Provider Demographics
NPI:1285652065
Name:BOTTI, KASANDRA ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:KASANDRA
Middle Name:ANN
Last Name:BOTTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 FORBES FIELD CIR
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1905
Mailing Address - Country:US
Mailing Address - Phone:814-466-6779
Mailing Address - Fax:
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6701
Practice Address - Country:US
Practice Address - Phone:814-234-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-010604-L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH78496Medicare UPIN