Healthcare Provider Details

I. General information

NPI: 1740274745
Provider Name (Legal Business Name): JEFFERSON L BOULET PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N RIVER AVE
BUCKLEY WA
98321-8978
US

IV. Provider business mailing address

PO BOX 1268
BUCKLEY WA
98321-1268
US

V. Phone/Fax

Practice location:
  • Phone: 360-829-0625
  • Fax: 360-829-9860
Mailing address:
  • Phone: 360-829-0625
  • Fax: 360-829-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10003567
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: