Provider Demographics
NPI:1255933263
Name:BOUCHER, EMILY BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BROOKE
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 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1306
Mailing Address - Fax:937-522-7017
Practice Address - Street 1:3737 SOUTHERN BLVD
Practice Address - Street 2:BOONSHOFT BLD. FLOOR E
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-294-1489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1160683363A00000X
50.006744RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant