Basic Information
| Provider Information | |||||||||
| NPI: | 1316216054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTCHKO | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 LAVISTER DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080542642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096947298 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15000 MIDLANTIC DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562555479 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2011 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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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 | 363A00000X | 25MP00274700 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.