Provider Demographics
NPI:1083889273
Name:BOUCHARD, KAREN A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:A
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 WATERS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6200
Mailing Address - Country:US
Mailing Address - Phone:912-350-8712
Mailing Address - Fax:912-350-8753
Practice Address - Street 1:4750 WATERS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6200
Practice Address - Country:US
Practice Address - Phone:912-350-8712
Practice Address - Fax:912-350-8753
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA357708693AMedicaid
01299269OtherAMERIGROUP