Provider Demographics
NPI:1053884635
Name:BOUCHER, TODD MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4123
Mailing Address - Fax:970-624-2416
Practice Address - Street 1:16951 E QUINCY AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1901
Practice Address - Country:US
Practice Address - Phone:303-752-5480
Practice Address - Fax:303-752-5481
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
COPA.0005535363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical