Provider Demographics
NPI:1336195064
Name:BOULET, ANDREW J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:BOULET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:122 W 7TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2349
Mailing Address - Country:US
Mailing Address - Phone:509-838-7711
Mailing Address - Fax:509-747-4664
Practice Address - Street 1:122 W 7TH AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2349
Practice Address - Country:US
Practice Address - Phone:509-838-7711
Practice Address - Fax:509-747-4664
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD28359207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003212600Medicaid
ID1124604Medicare ID - Type Unspecified