Provider Demographics
NPI:1316216054
Name:BUTCHKO, DANIELLE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:BUTCHKO
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 1:20 LAVISTER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2642
Mailing Address - Country:US
Mailing Address - Phone:609-694-7298
Mailing Address - Fax:
Practice Address - Street 1:15000 MIDLANTIC DR STE 102
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1573
Practice Address - Country:US
Practice Address - Phone:856-255-5479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00274700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant