Provider Demographics
NPI:1861959017
Name:BOUTWELL, JUSTIN (PA)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:BOUTWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-1378
Mailing Address - Country:US
Mailing Address - Phone:308-991-4571
Mailing Address - Fax:308-872-2027
Practice Address - Street 1:145 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-1378
Practice Address - Country:US
Practice Address - Phone:308-872-2486
Practice Address - Fax:308-872-2027
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2387363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program