Provider Demographics
NPI:1669459178
Name:BUTLER, LAURIE DASSO (PA)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:DASSO
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:2344 BOSTON RD
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1104
Practice Address - Country:US
Practice Address - Phone:413-596-5550
Practice Address - Fax:413-794-2551
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1829Medicare PIN
P72201Medicare UPIN