Lisa Marie Boucher, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

5601005490 Issued in MI

Practice address

2333 Biddle Ave
Wyandotte, MI 48192-4668

Phone

(734) 246-6000

NPI assigned

Jun 7, 2009

Sex

Female

Sole proprietor

No

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Henry Ford Wyandotte Hospital

  • Physician Assistant
  • Wyandotte, MI
  • NPI 1710315932
  NPD (past)

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Feb 21, 2017.

{
    "created_epoch": "1244332800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1487635200000",
    "number": "1679709463",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1640 FORT ST",
            "address_2": "SUITE D ATTNE DENISE",
            "city": "TRENTON",
            "state": "MI",
            "postal_code": "481832040",
            "telephone_number": "734-391-3057",
            "fax_number": "734-391-3052"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2333 BIDDLE AVE",
            "city": "WYANDOTTE",
            "state": "MI",
            "postal_code": "481924668",
            "telephone_number": "734-246-6000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOUCHER",
        "first_name": "LISA",
        "middle_name": "MARIE",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2009-06-07",
        "last_updated": "2017-02-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "5601005490",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "0H28864",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Bridget Antonia Bonello, FPN
• Joyce A Bonventre, RN
• Micah Noel Boone, DO
• Austin Henry Boots
• Michael D Bork, DO
• Jimmy Roger Boutin, M.D.
• Crystal Bowen, FNP
• Alexe Bowlby
• Haroutioun Boyajian, MD
• Harold Brabon, DPM

• All providers in Wyandotte, MI
• Physician Assistant in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.