Provider Demographics
NPI:1962810366
Name:BUTLER, ROGER II (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BUTLER
Suffix:II
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-1702
Mailing Address - Country:US
Mailing Address - Phone:606-528-2124
Mailing Address - Fax:606-528-8272
Practice Address - Street 1:121 BISHOP ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1702
Practice Address - Country:US
Practice Address - Phone:606-528-2124
Practice Address - Fax:606-528-8272
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK192150Medicare UPIN