Basic Information
| Provider Information | |||||||||
| NPI: | 1336108653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTT | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 01/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP 2853722 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 054356 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G3301 | 01 | FL | BLUE CROSS | OTHER | P00394595 | 01 | TX | MEDICARE RAILROAD | OTHER | 185859901 | 05 | TX | MEDICAID | 88598U | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 185859902 | 05 | TX | MEDICAID | P00671245 | 01 | TX | MEDICARE RAILROAD | OTHER | 305301600 | 05 | FL | MEDICAID | 87063U | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |