=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386195345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANE BUTEAU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2016
-----------------------------------------------------
Last Update Date | 11/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 NELSON BROGDON BLVD STE 250
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30518-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-442-1911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4361 SW 160TH AVE APT 103
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-5753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-870-6282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 9101
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------