Provider Demographics
NPI:1821496829
Name:BOOTZ, JOSHUA
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:
Last Name:BOOTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 FOX GLEN DR
Mailing Address - Street 2:APT 190
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-4307
Mailing Address - Country:US
Mailing Address - Phone:507-269-6020
Mailing Address - Fax:
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704220624367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered