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General NPI Number Information
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NPI Number | 1013268218
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Entity Type | Individual
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Provider Name | SAMANTHA LYNN BOUTHILLETTE PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/27/2012
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Last Update Date | 07/01/2024
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Provider Practice Location Address
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Address Line | 300 BIRNIE AVE
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City | SPRINGFIELD
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State | MA
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Zip | 01107-1107
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Country | US
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Telephone | 413-785-4666
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Fax |
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Provider Business Mailing Address
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Address Line | 9 BRENDA DR
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City | WESTFIELD
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State | MA
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Zip | 01085-4601
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Country | US
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Telephone | 413-454-2782
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 2833
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA5512
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA5512
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License Number State | MA
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