Provider Demographics
NPI:1649562489
Name:BOISCLAIR, PAULA JAYNE (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JAYNE
Last Name:BOISCLAIR
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4399 35TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-3722
Mailing Address - Country:US
Mailing Address - Phone:727-525-3959
Mailing Address - Fax:727-527-9695
Practice Address - Street 1:4399 35TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714-3722
Practice Address - Country:US
Practice Address - Phone:727-525-3959
Practice Address - Fax:727-527-9695
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4195156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630114200Medicaid