Provider Demographics
NPI:1376514216
Name:BUTLER, LISA (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28572 STATE HIGHWAY T
Mailing Address - Street 2:
Mailing Address - City:EXCELLO
Mailing Address - State:MO
Mailing Address - Zip Code:65247-2206
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:
Practice Address - Street 1:1515 UNION AVE
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9407
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO098504367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO125164OtherMO BCBS