Provider Demographics
NPI:1629440938
Name:BUTNER, BRENT (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BUTNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FORTINO BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1890
Mailing Address - Country:US
Mailing Address - Phone:970-261-5183
Mailing Address - Fax:
Practice Address - Street 1:1800 FORTINO BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1890
Practice Address - Country:US
Practice Address - Phone:970-261-5183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2018367500000X
COAPN.0992033-CRNA367500000X
TXAP129705367500000X
IL209019505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered