Healthcare Provider Details

I. General information

NPI: 1144638859
Provider Name (Legal Business Name): REVAZ BOUKIA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MAPLE ST
ASHLAND OR
97520-1552
US

IV. Provider business mailing address

2825 E BARNETT RD MSS
MEDFORD OR
97504-8332
US

V. Phone/Fax

Practice location:
  • Phone: 541-201-4000
  • Fax: 541-488-7437
Mailing address:
  • Phone: 541-789-4281
  • Fax: 541-789-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA228829
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: