Individual
ELLIOTT BUTLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3400 MCCLURE BRIDGE RD, B201, DULUTH, GA 30096-6675
(678) 957-8801
(678) 957-8804
Mailing address
PO BOX 3460, DULUTH, GA 30096-0059
(678) 957-8801
(678) 957-8804
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
0044308
GA
363AS0400X
Surgical Physician Assistant
Primary
000870
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100002796A
—
GA
01
—
1619959756
NATIONAL PROVIDER IDENTIFIER
GA
01
—
202I975412
MEDICARE PTAN
GA
Enumeration date
11/15/2005
Last updated
11/24/2009
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