Provider Demographics
NPI:1851300255
Name:BOUTON SEMMEL, KATHY (PA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BOUTON SEMMEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8560
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:21 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-1422
Practice Address - Country:US
Practice Address - Phone:207-862-0300
Practice Address - Fax:207-907-1041
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME300640099Medicaid
MEAP1648Medicare ID - Type Unspecified
ME300640099Medicaid