Provider Demographics
NPI:1093763617
Name:BUTLER, MELISSA R (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:BUTLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:R
Other - Last Name:HIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5824 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3072
Mailing Address - Country:US
Mailing Address - Phone:315-251-3105
Mailing Address - Fax:315-552-6018
Practice Address - Street 1:5719 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1985
Practice Address - Country:US
Practice Address - Phone:315-251-3100
Practice Address - Fax:315-449-9923
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302431363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02694526Medicaid
NY02694526Medicaid
NYPENDINGMedicare PIN