Provider Demographics
NPI:1023454204
Name:BOUCHARD, MARYSE (MD)
Entity type:Individual
Prefix:
First Name:MARYSE
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5371
Mailing Address - Street 2:4800 SANDPOINT WAY NE, W-7706
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-0371
Mailing Address - Country:US
Mailing Address - Phone:206-987-0104
Mailing Address - Fax:206-987-3852
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:W-7706
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-0371
Practice Address - Country:US
Practice Address - Phone:206-987-0104
Practice Address - Fax:206-987-3852
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2014-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60349185207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery