Provider Demographics
NPI:1366451890
Name:BUTZIRUS, GORDON (PA-C)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:BUTZIRUS
Suffix:
Gender:M
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 1:601 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-3319
Mailing Address - Country:US
Mailing Address - Phone:580-286-6688
Mailing Address - Fax:580-286-6699
Practice Address - Street 1:601 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-3319
Practice Address - Country:US
Practice Address - Phone:580-286-6688
Practice Address - Fax:580-286-6699
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA45363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid
OKPENDINGMedicaid
OKPENDINGMedicaid