Provider Demographics
NPI:1336108653
Name:BOTT, PETER KENNETH (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:KENNETH
Last Name:BOTT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 FOUNTAIN VIEW DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4832
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4832
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2853722367500000X
TX054356367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3301OtherBLUE CROSS
TXP00394595OtherMEDICARE RAILROAD
TX185859901Medicaid
TX88598UOtherBLUE CROSS BLUE SHIELD
TX185859902Medicaid
TXP00671245OtherMEDICARE RAILROAD
FL305301600Medicaid
TX87063UOtherBLUE CROSS BLUE SHIELD
TX8J6692Medicare PIN
TX185859902Medicaid
TX87063UOtherBLUE CROSS BLUE SHIELD
TX185859901Medicaid
TX8K9503Medicare PIN