Basic Information
| Provider Information | |||||||||
| NPI: | 1750908646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JEREMIAH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2462 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841102462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1348 S 18TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042619108 | ||||||||
| FaxNumber: | 9042619911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2020 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | APRN1107256 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | APRN11007256 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | APRN11007256 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.