Provider Demographics
NPI:1649539743
Name:BOTHWELL, ANGELA SUZANNE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:SUZANNE
Last Name:BOTHWELL
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 1:8990 SPRINGBROOK DR NW STE 250
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5884
Mailing Address - Country:US
Mailing Address - Phone:763-398-1176
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW STE 250
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5884
Practice Address - Country:US
Practice Address - Phone:763-398-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN089228367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered