Provider Demographics
NPI:1285026559
Name:BUETTNER, NANCY (PA-C)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BUETTNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-291-6187
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:709 HOLLYBROOK DR STE 4500
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2412
Practice Address - Country:US
Practice Address - Phone:903-291-6109
Practice Address - Fax:903-291-6013
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
TXPA09717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344775702Medicaid
TX401814YKS4Medicare PIN