Basic Information
Provider Information | |||||||||
NPI: | 1851300255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOUTON SEMMEL | ||||||||
FirstName: | KATHY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT | ||||||||
Address2: | PO BOX 7291 | ||||||||
City: | LEWISTON | ||||||||
State: | ME | ||||||||
PostalCode: | 042437291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077778560 | ||||||||
FaxNumber: | 2077778800 | ||||||||
Practice Location | |||||||||
Address1: | 21 WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | HAMPDEN | ||||||||
State: | ME | ||||||||
PostalCode: | 044441422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078620300 | ||||||||
FaxNumber: | 2079071041 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 02/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1051 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 300640099 | 05 | ME |   | MEDICAID |