Healthcare Provider Details

I. General information

NPI: 1861959017
Provider Name (Legal Business Name): JUSTIN BOUTWELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MEMORIAL DR
BROKEN BOW NE
68822-1378
US

IV. Provider business mailing address

145 MEMORIAL DR
BROKEN BOW NE
68822-1378
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-2486
  • Fax: 308-872-2027
Mailing address:
  • Phone: 308-991-4571
  • Fax: 308-872-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2387
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: