Basic Information
Provider Information | |||||||||
NPI: | 1548344948 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUTLER | ||||||||
FirstName: | LUCY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RICHARDSON | ||||||||
OtherFirstName: | LUCY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 6600 BRUCEVILLE RD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958234671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094686937 | ||||||||
FaxNumber: | 2094687042 | ||||||||
Practice Location | |||||||||
Address1: | 500 W HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | FRENCH CAMP | ||||||||
State: | CA | ||||||||
PostalCode: | 952319693 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094686937 | ||||||||
FaxNumber: | 2094687042 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 01/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA18513 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | PA18513 | 01 | CA | LICENSE | OTHER | MR1456412 | 01 | CA | DEA | OTHER |