Provider Demographics
NPI:1568464337
Name:BUTKUS, DIANE (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BUTKUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:PANGONIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-1117
Practice Address - Country:US
Practice Address - Phone:570-271-6621
Practice Address - Fax:570-271-6762
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-275700-L163W00000X
PA044096367500000X
PARN275700L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA60929OtherGEISINGER
PA032221501OtherCAPITAL ADVANTAGE
PA0782475000OtherIBC
PA859828OtherHIGHMARK
PA015172Medicare PIN
PA015172QCYMedicare PIN