Provider Demographics
NPI:1881656189
Name:BUTLAK, DAVID JONATHAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JONATHAN
Last Name:BUTLAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WHITEROCK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-8101
Mailing Address - Country:US
Mailing Address - Phone:704-326-6886
Mailing Address - Fax:
Practice Address - Street 1:218 OLD MOCKSVILLE RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1930
Practice Address - Country:US
Practice Address - Phone:704-838-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC160852367500000X
SC2690367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1433Medicaid
SCQ339723365Medicare PIN