Healthcare Provider Details

I. General information

NPI: 1144090507
Provider Name (Legal Business Name): DANIEL BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 110
FORT WAYNE IN
46845-1673
US

IV. Provider business mailing address

1928 STEUP AVE
FORT WAYNE IN
46808-2252
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6780
  • Fax: 260-425-6789
Mailing address:
  • Phone: 810-689-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004290A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: