Healthcare Provider Details

I. General information

NPI: 1457927204
Provider Name (Legal Business Name): MICHAELA SOPHIA BUTLER PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S WOODRUFF AVE STE 9
IDAHO FALLS ID
83404-6371
US

IV. Provider business mailing address

2001 S WOODRUFF AVE STE 9
IDAHO FALLS ID
83404-6371
US

V. Phone/Fax

Practice location:
  • Phone: 208-419-3002
  • Fax: 208-656-5652
Mailing address:
  • Phone: 208-419-3002
  • Fax: 208-656-5652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: