Provider Demographics
NPI:1205207362
Name:BUTLER, LATASHA SHANNON (PA)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:SHANNON
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2304 W MERCURY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3115
Practice Address - Country:US
Practice Address - Phone:757-951-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005040363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical