Provider Demographics
NPI:1952972176
Name:BUTAWAN, BRANDON LEUTERIO (RN, LVN)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEUTERIO
Last Name:BUTAWAN
Suffix:
Gender:M
Credentials:RN, LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W CARSON ST APT 14
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-6907
Mailing Address - Country:US
Mailing Address - Phone:310-467-3305
Mailing Address - Fax:
Practice Address - Street 1:410 W CARSON ST APT 14
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-6907
Practice Address - Country:US
Practice Address - Phone:310-467-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95247967163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92321944G08358OtherMEDI-CAL