Provider Demographics
NPI:1639918980
Name:BUTALLA, SYDNEY ANN (OD)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:ANN
Last Name:BUTALLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22976 185TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8935
Mailing Address - Country:US
Mailing Address - Phone:763-354-4024
Mailing Address - Fax:
Practice Address - Street 1:152 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4123
Practice Address - Country:US
Practice Address - Phone:207-775-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program