Provider Demographics
NPI:1972578094
Name:BOUCHER, DOUGLAS E (PA C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:E
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:115 WOODBINE LANE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-5208
Practice Address - Country:US
Practice Address - Phone:570-271-6621
Practice Address - Fax:570-271-5655
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA000486L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R06309Medicare UPIN
PA144263Medicare ID - Type Unspecified