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General NPI Number Information
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NPI Number | 1750677605
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Entity Type | Individual
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Provider Name | MARC ANTHONY BOUCHARD DO
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Gender | Male
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Dates
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Enumeration Date | 06/20/2011
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Last Update Date | 05/29/2024
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Provider Practice Location Address
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Address Line | 1615 DELAWARE ST
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City | LONGVIEW
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State | WA
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Zip | 98632-2367
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Country | US
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Telephone | 360-636-4836
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Fax | 360-636-6792
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Provider Business Mailing Address
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Address Line | 2110 GALLOWS RD STE D
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City | VIENNA
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State | VA
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Zip | 22182-3962
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Country | US
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Telephone | 603-858-0047
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Fax | 331-204-0820
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 0102203346
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | OP60942131
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License Number State | WA
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