Provider Demographics
NPI:1922405802
Name:BOTTASSO, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BOTTASSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4761
Mailing Address - Country:US
Mailing Address - Phone:907-456-4524
Mailing Address - Fax:907-456-5524
Practice Address - Street 1:3407 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4761
Practice Address - Country:US
Practice Address - Phone:907-456-4524
Practice Address - Fax:907-456-5524
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator