Healthcare Provider Details

I. General information

NPI: 1013268218
Provider Name (Legal Business Name): SAMANTHA LYNN BOUTHILLETTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA LYNN WHALEN PA-C

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BIRNIE AVE
SPRINGFIELD MA
01107-1107
US

IV. Provider business mailing address

9 BRENDA DR
WESTFIELD MA
01085-4601
US

V. Phone/Fax

Practice location:
  • Phone: 413-785-4666
  • Fax:
Mailing address:
  • Phone: 413-454-2782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2833
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA5512
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5512
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: