Healthcare Provider Details

I. General information

NPI: 1023247608
Provider Name (Legal Business Name): JESSICA FAYE BOUCHARD RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2009
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 MEDICAL CENTER DR
FAYETTEVILLE NY
13066-6613
US

IV. Provider business mailing address

4110 MEDICAL CENTER DR
FAYETTEVILLE NY
13066-6613
US

V. Phone/Fax

Practice location:
  • Phone: 315-663-0100
  • Fax: 315-663-0052
Mailing address:
  • Phone: 315-663-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number013312-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: