Provider Demographics
NPI:1386068310
Name:BOUCHER, MICHAEL D (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:141 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-2728
Mailing Address - Country:US
Mailing Address - Phone:212-257-2424
Mailing Address - Fax:
Practice Address - Street 1:3808 14TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3610
Practice Address - Country:US
Practice Address - Phone:718-972-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026903363A00000X
NV1612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP01718733OtherRAILROAD MEDICARE
NV1386068310Medicaid
NV1386068310Medicaid