Provider Demographics
NPI:1639440316
Name:BUTLER, JASON N (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:N
Last Name:BUTLER
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 1:11115 AMMAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3376
Mailing Address - Country:US
Mailing Address - Phone:662-216-9978
Mailing Address - Fax:
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-968-1000
Practice Address - Fax:601-944-9780
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-58009367500000X
MSR879866367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered