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General NPI Number Information
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NPI Number | 1538132261
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Entity Type | Individual
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Provider Name | ELIETTE YADIRA BOUIE PA-C
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Gender | Female
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Dates
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Enumeration Date | 02/13/2006
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | GONZAGA INTERVENTIONAL PAIN MANAGEMENT 957 NATIONAL HWY
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City | LAVALE
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State | MD
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Zip | 21502-0001
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Country | US
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Telephone | 240-362-7128
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Fax | 240-362-7731
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Provider Business Mailing Address
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Address Line | 12356 WILLIAMSPORT PIKE
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City | GREENCASTLE
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State | PA
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Zip | 17225-8436
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Country | US
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Telephone | 520-395-5881
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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 | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | C0003577
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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