Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 61656 | MN |
Y | 111NI0900X | Internist | 61656 | MN |
N | 207R00000X | Internist | R10068 | IA |
N | 111NI0900X | Internist | R10068 | IA |
NPI | 1003220799 |
---|---|
Provider Name | Jessica M Butanis |
First Address | Alexandria, MN 56308 |
Second Address | Alexandria, MN 56308-3426 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2014 |
Last Update Date | 23/01/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003220799 | (05) | MN |
H400413191 | MEDICARE (01) | MN |