Healthcare Provider Details

I. General information

NPI: 1720003213
Provider Name (Legal Business Name): ROBERT A BUTH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N84 W16889 MENOMONEE AVENUE
MENOMONEE FALLS WI
53051
US

IV. Provider business mailing address

3003 W GOOD HOPE ROAD
MILWAUKEE WI
53209
US

V. Phone/Fax

Practice location:
  • Phone: 262-251-7500
  • Fax: 262-251-7128
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number846
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: