Provider Demographics
NPI:1154417202
Name:BUTLER, TINA M (PA-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 4232
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-4232
Mailing Address - Country:US
Mailing Address - Phone:432-580-5891
Mailing Address - Fax:432-582-2302
Practice Address - Street 1:500 E 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5110
Practice Address - Country:US
Practice Address - Phone:432-580-8686
Practice Address - Fax:432-582-2302
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02260363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85N121Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TXS89032Medicare UPIN