Provider Demographics
NPI:1104690064
Name:BOUTIN, MATTHEW JAY
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAY
Last Name:BOUTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6445 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-3603
Mailing Address - Country:US
Mailing Address - Phone:520-603-4286
Mailing Address - Fax:
Practice Address - Street 1:6445 E 42ND ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-3603
Practice Address - Country:US
Practice Address - Phone:520-603-4286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN156068363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health