Provider Demographics
NPI:1639785561
Name:BOUGHTON, NICHOLAS GRANT THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GRANT THOMAS
Last Name:BOUGHTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:GRANT
Other - Last Name:BOUGHTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TRIPLER ARMY MEDICAL CENTER
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-6661
Mailing Address - Fax:808-433-1551
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-6661
Practice Address - Fax:808-433-1551
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant