Provider Demographics
NPI:1720088446
Name:BOTTGER, JUDITH A (CRNA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:BOTTGER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:4405 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1140
Practice Address - Country:US
Practice Address - Phone:712-239-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD042389367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2553990Medicaid
IA33480OtherBLUE CROSS OF IA
NE10024954000Medicaid
IA3553990Medicaid
R013639OtherDAKOTACARE
SD0040726OtherBLUE CROSS OF SD
NE08652OtherBLUE CROSS OF NE
SD5753240Medicaid
7511OtherAVERA HEALTH PLANS
IAI7807Medicare ID - Type Unspecified
IA2553990Medicaid
SD430077937Medicare ID - Type UnspecifiedRAILROAD
NE430015851Medicare ID - Type UnspecifiedRAILROAD
NE08652OtherBLUE CROSS OF NE
R013639OtherDAKOTACARE