Provider Demographics
NPI:1679709463
Name:BOUCHER, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:1640 FORT ST
Mailing Address - Street 2:SUITE D ATTNE DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2040
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-07
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H28864OtherBLUE CROSS
MIQ24657055Medicare PIN