Provider Demographics
NPI:1295906675
Name:BOETTCHER, BRADLEY J (CRNA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-445-7222
Practice Address - Fax:920-445-7289
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3411367500000X
WI141347163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI141347OtherRN SECONDARY WI STATE LICENSE
WI3411OtherWI STATE LICENSE
WI3411OtherWI STATE LICENSE
211790109Medicare PIN
WI211050111Medicare Oscar/Certification