Provider Demographics
NPI:1508571498
Name:BOUCHER, TYLER EUGENE (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:EUGENE
Last Name:BOUCHER
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 1:3736 GYMNAST WAY
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-7217
Mailing Address - Country:US
Mailing Address - Phone:406-740-0689
Mailing Address - Fax:
Practice Address - Street 1:2223 MISSION WAY
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-0160
Practice Address - Country:US
Practice Address - Phone:406-237-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-116768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant