Provider Demographics
NPI:1689897209
Name:BUTLER, WANDLE KEITH (PAC)
Entity Type:Individual
Prefix:MR
First Name:WANDLE
Middle Name:KEITH
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2002
Mailing Address - Country:US
Mailing Address - Phone:912-260-1206
Mailing Address - Fax:912-383-7820
Practice Address - Street 1:306 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3530
Practice Address - Country:US
Practice Address - Phone:912-383-7826
Practice Address - Fax:912-383-7299
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000954CMedicaid
GA202I976980Medicare PIN