Provider Demographics
NPI:1215740501
Name:BOUTROS, MARIANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:BOUTROS
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 FOREST HILL BLVD RM 100
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6141
Mailing Address - Country:US
Mailing Address - Phone:561-798-1649
Mailing Address - Fax:
Practice Address - Street 1:10111 FOREST HILL BLVD RM 100
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6141
Practice Address - Country:US
Practice Address - Phone:561-798-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant