1649880543 NPI number — ALLISON JOY BOUTWELL PA-C

Table of content: NATHAN W SUMMERS PA-C (NPI 1952355331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649880543 NPI number — ALLISON JOY BOUTWELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUTWELL
Provider First Name:
ALLISON
Provider Middle Name:
JOY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FINCH
Provider Other First Name:
ALLISON
Provider Other Middle Name:
JOY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649880543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-264-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 PARKWAY LN STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETAL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-544-7404
Provider Business Practice Location Address Fax Number:
601-584-6457
Provider Enumeration Date:
08/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114656800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com