Provider Demographics
NPI:1316703077
Name:BOTNER, RYAN J
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:J
Last Name:BOTNER
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:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0206
Mailing Address - Country:US
Mailing Address - Phone:701-415-6790
Mailing Address - Fax:
Practice Address - Street 1:712 6TH AVE
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:ND
Practice Address - Zip Code:58577-4355
Practice Address - Country:US
Practice Address - Phone:701-415-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator