Provider Demographics
NPI:1790105914
Name:BUTLER, MICHAEL JAMES (MSN, AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:BUTLER
Suffix:
Gender:M
Credentials:MSN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 BRENTWOOD PARK
Mailing Address - Street 2:
Mailing Address - City:NASHPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43830-8011
Mailing Address - Country:US
Mailing Address - Phone:740-328-7936
Mailing Address - Fax:
Practice Address - Street 1:751 FOREST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2868
Practice Address - Country:US
Practice Address - Phone:740-455-7670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-27
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003031294163W00000X
MO2014008350363LA2100X
OHCOA.15957-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105686Medicaid