WANDLE KEITH BUTLER, PAC — NPI 1689897209 (Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers

CMS-1500 Box 24J / 33a • NPI

1689897209

Type 1 Individual Rendering/Ordering

HIPAA NUCC Taxonomy • CMS Code

363A00000X (CMS 97)

Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant

Box 32 Service Location & ZIP+4

306 WESTSIDE DR, DOUGLAS, GA, 31533-3530

✓ 9-Digit EDI 837 ZIP+4 (31533-3530)

Practice Phone & Referral Fax

(912) 383-7826

Fax: (912) 383-7299

⚠️ HHS OIG LEIE FEDERAL EXCLUSION ALERT: NPI 1689897209 matches an active entry in the HHS Office of Inspector General List of Excluded Individuals/Entities (Sec. 1128(a)(4) — Felony Controlled Substance Conviction — Effective 2023-05-18). Verify before submitting Medicare/Medicaid claims.

CMS Medicare Order & Referring PECOS Eligibility

This practitioner does not currently appear in the CMS individual Order & Referring PECOS file (may practice in pediatrics, commercial-only networks, or hospital-employed settings).

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1689897209` (NPI-1 Individual Practitioner)
Provider / Legal Name	WANDLE KEITH BUTLER, PAC
Plain-English Specialty	Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant NUCC Code: `363A00000X` (Physician Assistant)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	306 WESTSIDE DR, DOUGLAS, GA, 31533-3530
Practice Telephone / Fax	Tel: (912) 383-7826 \| Fax: (912) 383-7299
Administrative Mailing Address	410 SHIRLEY AVE, DOUGLAS, GA, 31533-2002
Enumeration & Last Sync	Enumerated: 2007-04-11 \| CMS Record Updated: 2016-11-09

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

306 WESTSIDE DR, DOUGLAS, GA, 31533-3530

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Plain-English Taxonomy & CMS Crosswalk (363A00000X)

What Does Taxonomy Code 363A00000X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363A00000X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 97 (Physician Assistant)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Physician Assistant for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (WANDLE KEITH BUTLER, PAC)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`363A00000X` — Physician Assistant Plain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant	State: GA \| License: `003196` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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WANDLE KEITH BUTLER, PAC (NPI #1689897209)