Basic Information
| Provider Information | |||||||||
| NPI: | 1518479641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 NORRIS AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372043708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156951455 | ||||||||
| FaxNumber: | 6156951483 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 23RD AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159639200 | ||||||||
| FaxNumber: | 6159639201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2017 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1143940 | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3422 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.