Healthcare Provider Details

I. General information

NPI: 1992642706
Provider Name (Legal Business Name): EMMA LUCILLE POOL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMMA LUCILLE BOUSKY PA-C

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 ALVARADO RD STE 308
SAN DIEGO CA
92120-5268
US

IV. Provider business mailing address

5231 AUGUSTANA PL
SAN DIEGO CA
92115-3514
US

V. Phone/Fax

Practice location:
  • Phone: 619-265-7912
  • Fax:
Mailing address:
  • Phone: 309-621-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: