Provider Demographics
NPI:1821051012
Name:BUTLER, TRACEY M (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:M
Last Name:BUTLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:M
Other - Last Name:FOCHT-TILTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-729-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-09
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1103844367500000X
OHRN.395377367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01356545OtherMEDICARE RAILROAD
OHH190010OtherMEDICARE PTAN
OH000000838469OtherANTHEM BCBS
OH2643812Medicaid