MEDICARE: LISA BUTLER CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	098504	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	125164	OTHER	MO	MO BCBS

General Provider Information

NPI Number	:	1376514216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BUTLER CRNA

Provider Business Mailing Address
First Line	:	28572 STATE HIGHWAY T
Second Line	:
City	:	EXCELLO
State	:	MO
Zip	:	65247-2206
Country	:	US
Telephone Number	:	573-686-5550
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 UNION AVE
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-9407
Country	:	US
Telephone Number	:	573-686-5550
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	11/27/2007

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