Provider Demographics
NPI:1992741599
Name:BOOTHBY, JOHN F (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:BOOTHBY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:408 HAZEN ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1019
Practice Address - Country:US
Practice Address - Phone:269-657-1325
Practice Address - Fax:269-657-1419
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN138136367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235131137OtherBCBSM
MIH06012002Medicare PIN
AZZ60941Medicare PIN