Provider Demographics
NPI:1821493040
Name:BUTCHER, MARISSA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:L
Other - Last Name:BURGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 19662
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9662
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-0253
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:SUITE PAV5B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-0253
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-005258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid