Provider Demographics
NPI:1962936831
Name:BOTNER, XIAOFENG S
Entity type:Individual
Prefix:
First Name:XIAOFENG
Middle Name:S
Last Name:BOTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 STONEBROOK CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-7216
Mailing Address - Country:US
Mailing Address - Phone:734-649-9096
Mailing Address - Fax:
Practice Address - Street 1:1104 STONEBROOK CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-7216
Practice Address - Country:US
Practice Address - Phone:734-649-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042712390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program