Provider Demographics
NPI:1588674865
Name:BOTILLER, BERNARD THEODORE (PA-C)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:THEODORE
Last Name:BOTILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 DUTCHMANS PKWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3340
Mailing Address - Country:US
Mailing Address - Phone:502-587-9660
Mailing Address - Fax:502-540-5615
Practice Address - Street 1:1451 HARRODSBURG ROAD
Practice Address - Street 2:SUITE D 304
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:UM
Practice Address - Phone:859-977-4000
Practice Address - Fax:859-977-5100
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA674363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002739Medicaid
KY95002739Medicaid
0621230Medicare ID - Type Unspecified