Provider Demographics
NPI:1881809549
Name:BOTTERILL, SARA ASHLEY (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ASHLEY
Last Name:BOTTERILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ASHLEY
Other - Last Name:MCCOWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1901 CONNECTICUT AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2554
Mailing Address - Country:US
Mailing Address - Phone:320-259-4100
Mailing Address - Fax:320-257-5523
Practice Address - Street 1:1901 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-259-4100
Practice Address - Fax:320-257-5523
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244146208100000X
MN65017208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881809549Medicaid
VA1881809549Medicaid
VAP00686666OtherMEDICARE RAILROAD
VVJ478AMedicare PIN
P01584712Medicare PIN