Healthcare Provider Details

I. General information

NPI: 1821493040
Provider Name (Legal Business Name): MARISSA LYNN BUTCHER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA L BURGE PA-C

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST SUITE PAV5B
SPRINGFIELD IL
62701-1041
US

IV. Provider business mailing address

PO BOX 19662
SPRINGFIELD IL
62794-9662
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-0253
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-005258
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: