Provider Demographics
NPI:1992741755
Name:BUTLER, MARVIN RAY (PA-C)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:RAY
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550643
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33655-0643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:542 THUNDERBIRD DR
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9704
Practice Address - Country:US
Practice Address - Phone:813-928-9743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53193363A00000X
FLPA2196207P00000X
NMPA2016-0022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290528100Medicaid
FL970008252OtherRAILROAD MEDICARE
FLE2113WMedicare PIN
FLS73616Medicare UPIN
FL290528100Medicaid
FLE2113VMedicare PIN
FLE2113ZMedicare ID - Type Unspecified