1285944769 NPI number — MRS. DARCIE ELLEN BOUCHARD PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285944769 NPI number — MRS. DARCIE ELLEN BOUCHARD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHARD
Provider First Name:
DARCIE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EMGE
Provider Other First Name:
DARCIE
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285944769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N RAINBOW BLVD SUITE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-259-1228
Provider Business Mailing Address Fax Number:
702-433-2477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N RAINBOW BLVD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-259-1228
Provider Business Practice Location Address Fax Number:
702-433-2477
Provider Enumeration Date:
10/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  153222 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA1312 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500629170 . This is a "DMAP/DEPARTMENT OF HUMAN SERVICES" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 69568060 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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