MEDICARE: SYDNEY BUTLER ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	2255A2300X	Athletic Trainer	IA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2255A2300X	OTHER		TRUMAN

General Provider Information

NPI Number	:	1881106821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY BUTLER ATC

Provider Business Mailing Address
First Line	:	3210 SPRING VALLEY LN APT D3
Second Line	:
City	:	CEDAR FALLS
State	:	IA
Zip	:	50613-4845
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1227 W 27TH ST
Second Line	:
City	:	CEDAR FALLS
State	:	IA
Zip	:	50614-0012
Country	:	US
Telephone Number	:	319-273-2311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	09/11/2019

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Directions to “ SYDNEY BUTLER ATC” Practice Location

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