Basic Information
| Provider Information | |||||||||
| NPI: | 1104565233 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTVONNOAN | ||||||||
| FirstName: | MATA | ||||||||
| MiddleName: | MARCH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 HENNESSY BLVD STE 2003B | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375340952 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD STE 2003B | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375340952 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2022 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | LA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 332058 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.