Provider Demographics
NPI:1487051025
Name:BOUCHARD, MAYA GRACE
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:GRACE
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1755
Mailing Address - Country:US
Mailing Address - Phone:774-644-7972
Mailing Address - Fax:
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-674-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5347207P00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine