Provider Demographics
NPI:1144913567
Name:BOTTS, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BOTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 SINCLAIR WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1358 BLUE OAKS BLVD. #300
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678
Practice Address - Country:US
Practice Address - Phone:916-899-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker