Basic Information
| Provider Information | |||||||||
| NPI: | 1568827590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JASMINE | ||||||||
| MiddleName: | CHEYENNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLER | ||||||||
| OtherFirstName: | JASMINE | ||||||||
| OtherMiddleName: | CHEYENNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1705 TARBORO ST SW | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523998040 | ||||||||
| FaxNumber: | 2523998778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2015 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
| 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 | 0010-06162 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.