Provider Demographics
NPI:1730285982
Name:BOUCHER, LISA JEAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JEAN
Last Name:BOUCHER
Suffix:
Gender:F
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:PO BOX 95000 LBX 7650
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 GREAT FALLS PLZ STE 21
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5966
Practice Address - Country:US
Practice Address - Phone:207-330-3950
Practice Address - Fax:207-330-3955
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5606363A00000X
MEPA646363A00000X
CT001342363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02209570Medicaid
NY02209570Medicaid
NY0F1041Medicare ID - Type Unspecified