Individual
JESSE ALLAN BOUTWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHYSICIAN ASSISTANT
Contact information
Practice address
1050 STATE HIGHWAY 16 S, BANDERA, TX 78003-4830
(830) 261-0684
Mailing address
1050 STATE HIGHWAY 16 S, BANDERA, TX 78003-4830
(830) 261-0684
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA00055
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
Z142263
PTAN
—
Enumeration date
01/23/2006
Last updated
10/17/2016
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