Provider Demographics
NPI:1790239150
Name:BUTLER, SAMUEL (PA-C MPAS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PA-C MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 NE 164TH ST APT 632
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4291
Mailing Address - Country:US
Mailing Address - Phone:979-216-6079
Mailing Address - Fax:
Practice Address - Street 1:2145 NE 164TH ST APT 632
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4291
Practice Address - Country:US
Practice Address - Phone:979-216-6079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant