Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 4704185591 | MI |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 4704185591 | MI |
NPI | 1588643175 |
---|---|
Provider Name | Roxanne M. Buterakos |
First Address | Flint, MI 48503-5902 |
Second Address | Flint, MI 48503-5902 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2006 |
Last Update Date | 09/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0B51149 | BLUE SHIELD (01) | MI |
0N84570005 | MEDICARE (01) | MI |
3433384 | (05) | MI |
S70136 | (02) | MI |