Individual
MS. LISA MARIE BOUCHER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2333 BIDDLE AVE, WYANDOTTE, MI 48192-4668
(734) 246-6000
Mailing address
1640 FORT ST, SUITE D ATTNE DENISE, TRENTON, MI 48183-2040
(734) 391-3057
(734) 391-3052
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601005490
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H28864
BLUE CROSS
MI
Enumeration date
06/07/2009
Last updated
02/21/2017
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