Healthcare Provider Details

I. General information

NPI: 1578585543
Provider Name (Legal Business Name): JOHN K BOUCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH AVE SUITE 223
YAKIMA WA
98902-3242
US

IV. Provider business mailing address

PO BOX 2947
YAKIMA WA
98907-2947
US

V. Phone/Fax

Practice location:
  • Phone: 509-248-6080
  • Fax: 509-248-9964
Mailing address:
  • Phone: 509-248-7849
  • Fax: 509-249-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00016820
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: