Provider Demographics
NPI:1477865145
Name:BOTT, JOHNA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNA
Middle Name:MARIE
Last Name:BOTT
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 1:1006 NEW MOODY LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9122
Mailing Address - Country:US
Mailing Address - Phone:502-222-0028
Mailing Address - Fax:502-222-0029
Practice Address - Street 1:2125 STATE ST STE 5
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4901
Practice Address - Country:US
Practice Address - Phone:502-222-0028
Practice Address - Fax:502-222-0029
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100130280Medicaid
KYP400020273Medicare Oscar/Certification