Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 4301090356 | MI |
Y | 208600000X | Surgeon | 4301090356 | MI |
N | 2086S0122X | Plastic and Reconstructive Surgery | 45896 | AZ |
NPI | 1134325012 |
---|---|
Provider Name | Adam Keith Boettcher |
First Address | Flagstaff, AZ 86001-3281 |
Second Address | Flagstaff, AZ 86001-3281 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2007 |
Last Update Date | 29/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P707631 | (05) | AZ |