Provider Demographics
NPI:1588397566
Name:BOUTIN, CAMRYN YUANHONG
Entity type:Individual
Prefix:
First Name:CAMRYN
Middle Name:YUANHONG
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 FENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-2647
Mailing Address - Country:US
Mailing Address - Phone:413-537-9721
Mailing Address - Fax:
Practice Address - Street 1:3640 MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1084
Practice Address - Country:US
Practice Address - Phone:413-537-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MAPA9438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program