Provider Demographics
NPI:1386072619
Name:BUTTERWORTH, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BUTTERWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 RIO GRANDE ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1137
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:512-324-8962
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:512-324-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX673757363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328704703Medicaid
TX328704702Medicaid
TX328704701Medicaid
TX328704704Medicaid
TX328704701Medicaid
TX320504YKZJMedicare PIN