Healthcare Provider Details

I. General information

NPI: 1861481145
Provider Name (Legal Business Name): THOMAS RICHARD BUTLER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WOMACK ARMY MEDICAL CENTER
FT BRAGG NC
28307-2639
US

IV. Provider business mailing address

PO BOX 72639
FORT BRAGG NC
28307-2639
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8962
  • Fax: 910-907-8087
Mailing address:
  • Phone: 910-907-8962
  • Fax: 910-907-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101534
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: