Provider Demographics
NPI:1669472551
Name:BOETTCHER, KATHLEEN M (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BOETTCHER
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 1:3970 DEPUTY BILL CANTREL MEMOIRAL RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040
Mailing Address - Country:US
Mailing Address - Phone:678-513-2273
Mailing Address - Fax:678-513-8869
Practice Address - Street 1:3970 DEPUTY BILL CANTREL MEMOIRAL RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:678-513-2273
Practice Address - Fax:678-513-8869
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00745363A00000X
WI1775-023363AM0700X
GA6565363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2769130Medicare PIN
WIQ24557Medicare UPIN