Basic Information
| Provider Information | |||||||||
| NPI: | 1043350929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 837 | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070390837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737400607 | ||||||||
| FaxNumber: | 9734220353 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 W 11TH ST | ||||||||
| Address2: | SAINT VINCENT'S MEDICAL CENTER | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100118305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126047000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010235 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.