Provider Demographics
NPI:1942856521
Name:BOTCHWAY, PERCY (ATC)
Entity Type:Individual
Prefix:
First Name:PERCY
Middle Name:
Last Name:BOTCHWAY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 CARMEL CT
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5882
Mailing Address - Country:US
Mailing Address - Phone:651-890-9103
Mailing Address - Fax:
Practice Address - Street 1:956 CARMEL CT
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5882
Practice Address - Country:US
Practice Address - Phone:651-890-9103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2681207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine