Provider Demographics
NPI:1427496249
Name:BOUCHARD, MARY REA (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:REA
Last Name:BOUCHARD
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 1:2511 OLD CORNWALLIS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-1869
Mailing Address - Country:US
Mailing Address - Phone:844-932-5700
Mailing Address - Fax:
Practice Address - Street 1:2511 OLD CORNWALLIS RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1869
Practice Address - Country:US
Practice Address - Phone:844-932-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04293363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical