Provider Demographics
NPI:1174134712
Name:BOUGHTON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOUGHTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13083 N SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090-3148
Mailing Address - Country:US
Mailing Address - Phone:225-439-4365
Mailing Address - Fax:
Practice Address - Street 1:433 BOLIVAR ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-7021
Practice Address - Country:US
Practice Address - Phone:505-568-4808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA230503367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered