Justin Boutwell, PA

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

2387 Issued in NE

Practice address

145 Memorial Dr
Broken Bow, NE 68822-1378

Phone

(308) 872-2486

Fax

(308) 872-2027

NPI assigned

Feb 25, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NE

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Phelps Memorial Health Center

  • Critical Access Hospital
  • Holdrege, NE
  • NPI 1629035936

  NE

  Medicare reassignment NPD
• Phelps Memorial Health Center

  • Certified Registered Nurse Anesthetist
  • Holdrege, NE
  • NPI 1871528851

  NE

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1551052800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1566172800000",
    "number": "1861959017",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "145 MEMORIAL DR",
            "city": "BROKEN BOW",
            "state": "NE",
            "postal_code": "688221378",
            "telephone_number": "308-991-4571",
            "fax_number": "308-872-2027"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 MEMORIAL DR",
            "city": "BROKEN BOW",
            "state": "NE",
            "postal_code": "688221378",
            "telephone_number": "308-872-2486",
            "fax_number": "308-872-2027"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1316 Logan St",
            "address_purpose": "LOCATION",
            "city": "Holdrege",
            "state": "NE",
            "postal_code": "689491448",
            "country_code": "US",
            "telephone_number": "308-991-4571",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOUTWELL",
        "first_name": "JUSTIN",
        "name_prefix": "Mr.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-02-25",
        "last_updated": "2019-08-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NE",
            "license": "2387",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Douglas James Bazyn, D.C.
• Lisa Berghorst
• Erin Boldt Reiff, ED.S.
• Norval Leon Books, M.D.
• Caitlin Boryca
• Andrew Michael Bowin, DPT
• David J Bresley
• Broken Bow Care and Rehabilitation Center, LLC
• Broken Bow Chiropractic Center, P.C.
• Broken Bow Clinic PC

• All providers in Broken Bow, NE
• Medical Physician Assistant in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.