Provider Demographics
NPI:1407807639
Name:BOTT, PAUL WILLIAM (PA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:WILLIAM
Last Name:BOTT
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2388 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-3433
Mailing Address - Country:US
Mailing Address - Phone:518-886-5412
Mailing Address - Fax:518-899-8069
Practice Address - Street 1:2388 ROUTE 9
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118-3433
Practice Address - Country:US
Practice Address - Phone:518-886-5412
Practice Address - Fax:518-899-8069
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY020811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGS771ZMedicare PIN