Jesse Allan Boutwell, PHYSICIAN ASSISTANT
Individual provider Active NPI Medical Physician Assistant · Bandera, TX
NPI 1912977117 · NPPES record last updated Oct 17, 2016
Key facts
- NPI
- 1912977117
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- License
- PA00055 (TX)
- Practice address
- 1050 State Highway 16 S
Bandera, TX 78003-4830 - Phone
- (830) 261-0684
- NPI assigned
- Jan 23, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2006
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Quality Acute Care PA
Practice addresses (Care Compare)
1421 S Main St
Boerne, TX 78006-3322
Phone (830) 249-9995
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040629001264 | TX | Practitioner - Physician Assistant | 6800708876 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- No
- HHS exclusion list flag
- The National Provider Directory flags this NPI as appearing on an HHS exclusion list.
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA00055 | TX | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Methodist Healthcare System of San Antonio, LTD., L.L.P. | Current |
Accepting new patients | |
| Third Coast Emergency Physicians Sid Peterson PA | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | PA00055 | TX | Yes |
Addresses
Primary practice location
1050 State Highway 16 S
Bandera, TX 78003-4830
Mailing address
1050 State Highway 16 S
Bandera, TX 78003-4830
Phone (830) 261-0684
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| Z142263 | Other | PTAN |
Other providers in Bandera, TX
- Deepa Basil
- Belinda Bego
- Cynthia Ann Bennett
- Dawn Zoe Blythe
- Mary Carla Bolan
- Boyles Bandera Pharmacy
- Andy Breitbarth
- Jamye Sue Buckley
- Priya Butcher
- Joyce Lynn Canion
All providers in Bandera, TX · Medical Physician Assistant in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 17, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.