Provider Demographics
NPI: | 1780835686 |
---|---|
Name: | BUTCH, JEFFREY MATTHEW (APN) |
Entity Type: | Individual |
Prefix: | |
First Name: | JEFFREY |
Middle Name: | MATTHEW |
Last Name: | BUTCH |
Suffix: | |
Gender: | M |
Credentials: | APN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 423 FORTRESS BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | MORGANTOWN |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 26508-1351 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 304-225-2500 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 423 FORTRESS BLVD |
Practice Address - Street 2: | |
Practice Address - City: | MORGANTOWN |
Practice Address - State: | WV |
Practice Address - Zip Code: | 26508-1351 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-225-2500 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-10-09 |
Last Update Date: | 2024-01-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 247955 | 363LF0000X |
PA | SP010350 | 363LF0000X |
MD | R246090 | 363LF0000X |
FL | APRN11009358 | 363LF0000X |
TX | AP139161 | 363LF0000X |
NJ | 26NJ00171600 | 363LF0000X |
IL | 277001156 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NJ | 139943XVA | Medicare UPIN |