Healthcare Provider Details

I. General information

NPI: 1598890816
Provider Name (Legal Business Name): MICHAEL ANTHONY BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL ANTHONY BUTLER OWNER

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7402 E PALO VERDE ST
PRESCOTT VALLEY AZ
86314-3213
US

IV. Provider business mailing address

7402 E PALO VERDE ST
PRESCOTT VALLEY AZ
86314-3213
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-6500
  • Fax: 928-636-0377
Mailing address:
  • Phone: 928-445-6500
  • Fax: 928-636-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number06-00005700
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: