Provider Demographics
NPI:1619959756
Name:BUTLER, ELLIOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3460
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0059
Mailing Address - Country:US
Mailing Address - Phone:678-957-8801
Mailing Address - Fax:678-957-8804
Practice Address - Street 1:3400 MCCLURE BRIDGE RD
Practice Address - Street 2:B201
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6675
Practice Address - Country:US
Practice Address - Phone:678-957-8801
Practice Address - Fax:678-957-8804
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0044308363AM0700X
GA000870363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I975412OtherMEDICARE PTAN
GA1619959756OtherNATIONAL PROVIDER IDENTIFIER
GA100002796AMedicaid
GAP69595Medicare UPIN
GA100002796AMedicaid