Provider Demographics
NPI:1497809677
Name:BUTTROM, DOROTHY J (CRNA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:J
Last Name:BUTTROM
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 1:2200 JEFFERSON AVENUE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1181
Mailing Address - Country:US
Mailing Address - Phone:419-251-2673
Mailing Address - Fax:419-251-0916
Practice Address - Street 1:485 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2611
Practice Address - Country:US
Practice Address - Phone:419-251-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA-03689367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2105564Medicaid