Provider Demographics
NPI:1811282981
Name:BOTTARO, VINCENT ANTHONY (PA-C)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:ANTHONY
Last Name:BOTTARO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:307 S FRONT ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4310 LONDONDERRY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5300
Practice Address - Country:US
Practice Address - Phone:717-791-2520
Practice Address - Fax:717-920-4361
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA054914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA324481Medicare PIN