Provider Demographics
NPI:1457505083
Name:BOUCHARD, GARY J (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:BOUCHARD
Suffix:
Gender:M
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 1:190 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-2120
Mailing Address - Country:US
Mailing Address - Phone:732-668-4192
Mailing Address - Fax:
Practice Address - Street 1:190 BROADWAY
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-2120
Practice Address - Country:US
Practice Address - Phone:732-668-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP 00002600363A00000X
NY003223363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant