Healthcare Provider Details

I. General information

NPI: 1376284158
Provider Name (Legal Business Name): CODY JAMES BUTLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MANNING BLVD
ALBANY NY
12208-1707
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-1550
  • Fax: 518-525-6545
Mailing address:
  • Phone: 518-525-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number028387
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: