Provider Demographics
NPI:1477528826
Name:BUTLER, JASON EDWARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:EDWARD
Last Name:BUTLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6839 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3402
Mailing Address - Country:US
Mailing Address - Phone:918-494-0612
Mailing Address - Fax:918-481-5170
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-0612
Practice Address - Fax:918-481-4170
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR090656163W00000X
ARC002907367500000X
OK201464367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA580628385OtherTRICARE
GA000977842AMedicaid
GA000977842HMedicaid
GA000977842AMedicaid