Provider Demographics
NPI:1215259668
Name:BOTTA, KELLY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BOTTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:340 N PLEASANT VALLEY RD PO BOX 4164
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601
Mailing Address - Country:US
Mailing Address - Phone:540-692-6132
Mailing Address - Fax:540-900-0959
Practice Address - Street 1:340 N PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-5608
Practice Address - Country:US
Practice Address - Phone:406-926-1325
Practice Address - Fax:540-900-0959
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110003257207R00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA100045Medicare PIN