Provider Demographics
NPI:1316390990
Name:BOUCHER, JOSHUA D (DO)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CHANNEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7837
Mailing Address - Country:US
Mailing Address - Phone:907-463-4074
Mailing Address - Fax:
Practice Address - Street 1:1200 SALMON CREEK LN
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7861
Practice Address - Country:US
Practice Address - Phone:907-463-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK197774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1736687Medicaid
AK197774OtherSTATE OF ALASKA