Provider Demographics
NPI:1134225592
Name:VITA, BOTOND A (PA)
Entity type:Individual
Prefix:
First Name:BOTOND
Middle Name:A
Last Name:VITA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-3000
Mailing Address - Fax:719-587-1372
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-8091
Practice Address - Fax:719-589-8112
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00380363A00000X
CO2460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COVIVI2460OtherANTHEM BC/BS
CO840255530069OtherROCKY MTN HEALTH PLANS
CO56582722Medicaid
COVIVI2460OtherANTHEM BC/BS
COS86841Medicare UPIN
COC809629Medicare PIN