Provider Demographics
NPI:1285795021
Name:BOUTTE, TEMICA DONESE (PA-C)
Entity type:Individual
Prefix:MS
First Name:TEMICA
Middle Name:DONESE
Last Name:BOUTTE
Suffix:
Gender:F
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 1:8317 ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-3629
Mailing Address - Country:US
Mailing Address - Phone:562-861-4504
Mailing Address - Fax:
Practice Address - Street 1:8317 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3629
Practice Address - Country:US
Practice Address - Phone:562-861-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15678363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical