Healthcare Provider Details

I. General information

NPI: 1205207362
Provider Name (Legal Business Name): LATASHA SHANNON BUTLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 TEXAS AVE
LOS BANOS CA
93635-3453
US

IV. Provider business mailing address

4818 ORIOLE DR
CHESAPEAKE VA
23321-1291
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 757-597-1581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110005040
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number67575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: