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General NPI Number Information
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NPI Number | 1619959756
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Entity Type | Individual
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Provider Name | ELLIOTT BUTLER PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/15/2005
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Last Update Date | 11/24/2009
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Provider Practice Location Address
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Address Line | 3400 MCCLURE BRIDGE RD B201
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City | DULUTH
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State | GA
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Zip | 30096-6675
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Country | US
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Telephone | 678-957-8801
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Fax | 678-957-8804
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Provider Business Mailing Address
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Address Line | PO BOX 3460
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City | DULUTH
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State | GA
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Zip | 30096-0059
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Country | US
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Telephone | 678-957-8801
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Fax | 678-957-8804
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0044308
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 000870
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License Number State | GA
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