Provider Demographics
NPI:1194356865
Name:BUTTA, HUSSEN WAKO
Entity Type:Individual
Prefix:
First Name:HUSSEN
Middle Name:WAKO
Last Name:BUTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 IDE CT
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2635
Mailing Address - Country:US
Mailing Address - Phone:612-578-7723
Mailing Address - Fax:
Practice Address - Street 1:2245 IDE CT
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2635
Practice Address - Country:US
Practice Address - Phone:612-578-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN394663251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health