Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0207X | Pediatric Hematology-Oncologist | 35.128089 | OH |
Y | 2080P0207X | Pediatric Hematology-Oncologist | 57181 | MN |
NPI | 1194083675 |
---|---|
Provider Name | Alexander Albert Boucher |
First Address | Minneapolis, MN 55455-4800 |
Second Address | Minneapolis, MN 55455-4800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2012 |
Last Update Date | 11/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1194083675 | (05) | MN |