Basic Information
Provider Information | |||||||||
NPI: | 1205801107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUTLER | ||||||||
FirstName: | WAYNE | ||||||||
MiddleName: | MITCHELL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1201 GRAMPIAN BLVD | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 177011900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8886479600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 740 HIGH ST | ||||||||
Address2: | SUITE 2001 | ||||||||
City: | WILLIAMSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 177013102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5703213165 | ||||||||
FaxNumber: | 5703213166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 04/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA000270L | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 104352600 | 05 | FL |   | MEDICAID | YD7WJ | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |