MEDICARE: JEFFERSON L BOULET PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA10003567	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740274745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERSON L BOULET PAC

Provider Business Mailing Address
First Line	:	PO BOX 1268
Second Line	:
City	:	BUCKLEY
State	:	WA
Zip	:	98321-1268
Country	:	US
Telephone Number	:	360-829-0625
Fax Number	:	360-829-9860

Provider Business Practice Location Address
First Line	:	305 N RIVER AVE
Second Line	:
City	:	BUCKLEY
State	:	WA
Zip	:	98321-8978
Country	:	US
Telephone Number	:	360-829-0625
Fax Number	:	360-829-9860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	03/07/2023

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Directions to “ JEFFERSON L BOULET PAC” Practice Location

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