Healthcare Provider Details

I. General information

NPI: 1710077276
Provider Name (Legal Business Name): MICHAEL JAMES BUTERA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PARKWAY
W. ROXBURY MA
02132
US

IV. Provider business mailing address

23 RIDEOUT LN
STOUGHTON MA
02072-3191
US

V. Phone/Fax

Practice location:
  • Phone: 617-323-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA169000
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: