Provider Demographics
NPI:1457927204
Name:BUTLER, MICHAELA SOPHIA (PA-S)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:SOPHIA
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:600 PIONEER RD APT 605
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4650 HAWTHORNE RD STE 3B
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-252-5621
Practice Address - Fax:208-648-4167
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2022-03-21
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant