Healthcare Provider Details

I. General information

NPI: 1124021704
Provider Name (Legal Business Name): DAVID BUTLER P.A-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 OFFICE PARK DR
PALM COAST FL
32137-3808
US

IV. Provider business mailing address

668 LAKE ASBURY DR
GREEN COVE SPRINGS FL
32043-9551
US

V. Phone/Fax

Practice location:
  • Phone: 386-447-6615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2669
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: