Provider Demographics
NPI:1508530429
Name:BOUCAN, SCOTT EMMANUEL
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:EMMANUEL
Last Name:BOUCAN
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 1:988 ORIOLE WAY SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-4136
Mailing Address - Country:US
Mailing Address - Phone:404-697-9142
Mailing Address - Fax:
Practice Address - Street 1:988 ORIOLE WAY SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-4136
Practice Address - Country:US
Practice Address - Phone:404-697-9142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program