Healthcare Provider Details

I. General information

NPI: 1285549006
Provider Name (Legal Business Name): VICTORY WEIGHT LOSS MEDICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BALCONES DR STE 100
AUSTIN TX
78731-4298
US

IV. Provider business mailing address

5900 BALCONES DR STE 100
AUSTIN TX
78731-4298
US

V. Phone/Fax

Practice location:
  • Phone: 512-318-2199
  • Fax:
Mailing address:
  • Phone: 512-318-2199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MATT BOUTTE
Title or Position: CO-OWNER
Credential: PA-C
Phone: 469-877-6278