Provider Demographics
NPI:1568437960
Name:BUTCHER, SHARON D (PNP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:D
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11870 SE AUSTRAILIS CT
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9608
Mailing Address - Country:US
Mailing Address - Phone:503-698-7503
Mailing Address - Fax:
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:STE 2225
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-4505
Practice Address - Fax:503-413-4719
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR095006346N2363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100124Medicaid
OR113839Medicare ID - Type Unspecified
OR100124Medicaid