Provider Demographics
NPI:1831730084
Name:BUTLER, KENDAL RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:KENDAL
Middle Name:RYAN
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:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 HEALTH CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4607
Practice Address - Country:US
Practice Address - Phone:217-238-3435
Practice Address - Fax:217-238-3492
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-008144363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant