Basic Information
| Provider Information | |||||||||
| NPI: | 1720088446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTTGER | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 4405 HAMILTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511041140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122393937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | D042389 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2553990 | 05 | IA | MEDICAID | 33480 | 01 | IA | BLUE CROSS OF IA | OTHER | 10024954000 | 05 | NE | MEDICAID | 3553990 | 05 | IA | MEDICAID | R013639 | 01 | DAKOTACARE | OTHER | 0040726 | 01 | SD | BLUE CROSS OF SD | OTHER | 08652 | 01 | NE | BLUE CROSS OF NE | OTHER | 5753240 | 05 | SD | MEDICAID | 7511 | 01 | AVERA HEALTH PLANS | OTHER |