Basic Information
| Provider Information | |||||||||
| NPI: | 1457589558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTTE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Credential: | PA-C, MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | BRENHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778335413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9793375000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 06/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MA053903 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA09060 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.