Healthcare Provider Details

I. General information

NPI: 1366847709
Provider Name (Legal Business Name): ELIZABETH REBMANN BUTLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOHNSON FERRY RD STE 130
ATLANTA GA
30342-1601
US

IV. Provider business mailing address

960 JOHNSON FERRY RD STE 130
ATLANTA GA
30342-1601
US

V. Phone/Fax

Practice location:
  • Phone: 404-300-2990
  • Fax: 404-300-2986
Mailing address:
  • Phone: 404-300-2990
  • Fax: 404-300-2986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0181291
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9847
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: