Provider Demographics
NPI:1376831115
Name:BUTSON, DAVID CHRISTIAN (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHRISTIAN
Last Name:BUTSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7401
Mailing Address - Country:US
Mailing Address - Phone:813-662-3376
Mailing Address - Fax:813-662-3009
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3019
Practice Address - Country:US
Practice Address - Phone:863-680-7000
Practice Address - Fax:863-680-7420
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003867300Medicaid
FLFE257ZMedicare PIN