Provider Demographics
NPI:1881911105
Name:BOISSONNEAULT, NINO (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NINO
Middle Name:
Last Name:BOISSONNEAULT
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 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:307 S. 13TH STREET, SUITE 300
Practice Address - Street 2:SKAGIT REGIONAL CLINICS - CARDIOLOGY
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274
Practice Address - Country:US
Practice Address - Phone:360-336-9757
Practice Address - Fax:360-814-5237
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60257982363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2016681Medicaid