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General NPI Number Information
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NPI Number | 1043553357
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Entity Type | Individual
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Provider Name | THADDEUS JASON BOUGHTON ANP-BC
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Gender | Male
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Dates
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Enumeration Date | 04/04/2013
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Last Update Date | 05/09/2019
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Provider Practice Location Address
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Address Line | 1110 E 6TH STREET SUITE E
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City | MUSCLE SHOALS
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State | AL
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Zip | 35661
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Country | US
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Telephone | 256-314-2431
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Fax | 256-314-2435
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Provider Business Mailing Address
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Address Line | 1110 E 6TH STREET SUITE E
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City | MUSCLE SHOALS
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State | AL
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Zip | 35661-3669
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Country | US
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Telephone | 256-314-2431
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 1139488
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License Number State | AL
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