Provider Demographics
NPI:1700868072
Name:BUTCHER, DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BUTCHER
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:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-1988
Mailing Address - Country:US
Mailing Address - Phone:903-723-2465
Mailing Address - Fax:903-677-5586
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-723-2465
Practice Address - Fax:903-677-5586
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60504663367500000X
TX571254367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0024689-02Medicaid
S97260Medicare UPIN
430066877Medicare PIN
TX0024689-02Medicaid