Provider Demographics
NPI:1902992795
Name:LUSTIG-BUTTS, ELEANOR FRANCES (CPNP)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:FRANCES
Last Name:LUSTIG-BUTTS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:ELEANOR
Other - Middle Name:FRANCES
Other - Last Name:LUSTIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:2310 MOUNTAIN VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1134
Mailing Address - Country:US
Mailing Address - Phone:541-883-3591
Mailing Address - Fax:541-883-2886
Practice Address - Street 1:2310 MOUNTAIN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1134
Practice Address - Country:US
Practice Address - Phone:541-883-3591
Practice Address - Fax:541-883-2886
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR089007521N2 PNP PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR013115Medicaid
OR013115Medicaid
BN111975Medicare ID - Type Unspecified