Provider Demographics
NPI:1245812320
Name:BOULDIN, DERRICK PAUL JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:PAUL
Last Name:BOULDIN
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:109 MILL WALK CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant