Healthcare Provider Details

I. General information

NPI: 1750337895
Provider Name (Legal Business Name): MICHELLE BOUCHER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MANCHESTER AVE SUITE #300
ORANGE CA
92868-3217
US

IV. Provider business mailing address

200 S MANCHESTER AVE SUITE # 300
ORANGE CA
92868-3217
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-3856
  • Fax:
Mailing address:
  • Phone: 714-456-3856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: