Basic Information
| Provider Information | |||||||||
| NPI: | 1144283797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLAK | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 WHITEROCK DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT HOLLY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281208101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043266885 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 3RD AVE NE | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283278105 | ||||||||
| FaxNumber: | 8253274245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 163893 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 2689 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | AN1432 | 05 | SC | MEDICAID |