Provider Demographics
NPI:1891919098
Name:BOOTS, TRICIA MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:TRICIA
Middle Name:MARIE
Last Name:BOOTS
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9146
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2001 EHRMAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-2271
Practice Address - Country:US
Practice Address - Phone:724-473-0660
Practice Address - Fax:714-473-0665
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002714L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034774070001Medicaid