Provider Demographics
NPI:1609379809
Name:BOUYACK, STEVEN ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:ROBERT
Last Name:BOUYACK
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 1:303 E TOWN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4601
Mailing Address - Country:US
Mailing Address - Phone:614-788-5000
Mailing Address - Fax:614-788-5100
Practice Address - Street 1:303 E TOWN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4601
Practice Address - Country:US
Practice Address - Phone:614-788-5000
Practice Address - Fax:614-788-5510
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005428RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.005428RXOtherSTATE MEDICAL BOARD OF OHIO
1149614OtherNCCPA
OH0315708Medicaid