Provider Demographics
NPI:1205801107
Name:BUTLER, WAYNE MITCHELL (PA-C)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:MITCHELL
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:888-647-9600
Mailing Address - Fax:
Practice Address - Street 1:740 HIGH ST
Practice Address - Street 2:SUITE 2001
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3102
Practice Address - Country:US
Practice Address - Phone:570-321-3165
Practice Address - Fax:570-321-3166
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000270L363A00000X, 363A00000X, 363AM0700X
FLPA9112411363AM0700X, 363AS0400X
PAOA002437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104352600Medicaid
FLYD7WJOtherBLUE CROSS BLUE SHIELD