Provider Demographics
NPI:1356618359
Name:BUTCHER, KRYSTAL ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:ANN
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:ANN
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAIDEN NAME
Mailing Address - Street 1:736 ROUTE 4
Mailing Address - Street 2:STE. 103
Mailing Address - City:SINAJANA
Mailing Address - State:GUAM
Mailing Address - Zip Code:96910
Mailing Address - Country:UM
Mailing Address - Phone:671-649-7232
Mailing Address - Fax:671-649-7233
Practice Address - Street 1:2219 YOUNGMAN AVE APT 2
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-3016
Practice Address - Country:US
Practice Address - Phone:763-204-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPA-83363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH107905Medicare UPIN