Basic Information
| Provider Information | |||||||||
| NPI: | 1861481145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 72639 | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283072639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078962 | ||||||||
| FaxNumber: | 9109078087 | ||||||||
| Practice Location | |||||||||
| Address1: | WOMACK ARMY MEDICAL CENTER | ||||||||
| Address2: | |||||||||
| City: | FT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283072639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078962 | ||||||||
| FaxNumber: | 9109078087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 101534 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | R40054 | 05 | NC | MEDICAID |