Provider Demographics
NPI:1144471970
Name:LEBOUTON, MELISSA CHRISTINE (PAC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHRISTINE
Last Name:LEBOUTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6771 W MINER TRL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3008
Mailing Address - Country:US
Mailing Address - Phone:623-748-8373
Mailing Address - Fax:623-748-8373
Practice Address - Street 1:14418 W MEEKER BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5283
Practice Address - Country:US
Practice Address - Phone:623-584-9500
Practice Address - Fax:623-584-4945
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4327363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4327OtherLICENSE