MEDICARE: MATTHEW JAY BOUTIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN156068	AZ

General Provider Information

NPI Number	:	1104690064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW JAY BOUTIN

Provider Business Mailing Address
First Line	:	6445 E 42ND ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85730-3603
Country	:	US
Telephone Number	:	520-603-4286
Fax Number	:

Provider Business Practice Location Address
First Line	:	6445 E 42ND ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85730-3603
Country	:	US
Telephone Number	:	520-603-4286
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2023
Last Update Date	:	11/10/2023

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