Provider Demographics
NPI:1144283797
Name:BUTLAK, LINDA MARIE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:MARIE
Last Name:BUTLAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WHITEROCK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-8101
Mailing Address - Country:US
Mailing Address - Phone:704-326-6885
Mailing Address - Fax:
Practice Address - Street 1:10 3RD AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-5044
Practice Address - Country:US
Practice Address - Phone:828-327-8105
Practice Address - Fax:825-327-4245
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC163893367500000X
SC2689367500000X
NC1043367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1432Medicaid
SCP00330005Medicare PIN
SCQ341353365Medicare PIN