Provider Demographics
NPI:1750337895
Name:BOUCHER, MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S MANCHESTER AVE
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3217
Mailing Address - Country:US
Mailing Address - Phone:714-456-3856
Mailing Address - Fax:
Practice Address - Street 1:200 S MANCHESTER AVE
Practice Address - Street 2:SUITE #300
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3217
Practice Address - Country:US
Practice Address - Phone:714-456-3856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP38014Medicare UPIN
CAWPA154641Medicare ID - Type Unspecified