Provider Demographics
NPI:1487225363
Name:BUTLER, BEAU (NP)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:366 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2711
Mailing Address - Country:US
Mailing Address - Phone:631-960-5060
Mailing Address - Fax:631-698-7714
Practice Address - Street 1:366 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2711
Practice Address - Country:US
Practice Address - Phone:631-960-5060
Practice Address - Fax:631-698-7714
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95183714163W00000X
FLRN9542421163W00000X
NY739576163W00000X
NY310774363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner