Provider Demographics
NPI:1679639561
Name:BOTTIAUX, BIANCA (PA)
Entity Type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:
Last Name:BOTTIAUX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-549-5128
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-549-5128
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBCBS OF IL
IL7210895OtherAETNA
IL444347OtherHEALTHLINK
IL037526OtherHAMP INS. #
IL143821Medicare Oscar/Certification
IL3932056OtherBCBS OF IL
ILK45739Medicare PIN
IL214881Medicare Oscar/Certification
IL7210895OtherAETNA