Provider Demographics
NPI:1851559108
Name:BUTLER, JACQUELINE (RPA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3412
Mailing Address - Country:US
Mailing Address - Phone:718-665-9340
Mailing Address - Fax:
Practice Address - Street 1:880 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3412
Practice Address - Country:US
Practice Address - Phone:718-665-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0041891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0041891OtherREGISTRATION