Provider Demographics
NPI:1417329202
Name:BOTSFORD, ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:BOTSFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 W COPELAND DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:321-841-7550
Mailing Address - Fax:321-841-8185
Practice Address - Street 1:89 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806
Practice Address - Country:US
Practice Address - Phone:321-841-7550
Practice Address - Fax:321-841-8185
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9109159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018439700Medicaid
FLPA9109159OtherMEDICAL LICENSE
FLPA9109159OtherMEDICAL LICENSE