Provider Demographics
NPI:1841214327
Name:BOUTIN, NANCY S (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:S
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14001
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-5014
Mailing Address - Country:US
Mailing Address - Phone:503-561-5419
Mailing Address - Fax:
Practice Address - Street 1:1015 3RD ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4007
Practice Address - Country:US
Practice Address - Phone:503-588-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD139242085R0001X, 2085H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085H0002XAllopathic & Osteopathic PhysiciansRadiologyHospice and Palliative Medicine
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004650Medicaid
ORR00WCGHFDMedicare PIN
OR004650Medicaid
C91296Medicare UPIN