Provider Demographics
NPI:1831290667
Name:BOTSFORD, KRISTA (PA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:BOTSFORD
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 1:9004 HOLLIROB LN
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-9171
Mailing Address - Country:US
Mailing Address - Phone:715-845-5532
Mailing Address - Fax:
Practice Address - Street 1:9004 HOLLIROB LN
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-9171
Practice Address - Country:US
Practice Address - Phone:715-845-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42934000Medicaid
WI42934000Medicaid
S35698Medicare UPIN