Provider Demographics
NPI:1538132261
Name:BOUIE, ELIETTE YADIRA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELIETTE
Middle Name:YADIRA
Last Name:BOUIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12356 WILLIAMSPORT PIKE
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:17225-8436
Mailing Address - Country:US
Mailing Address - Phone:520-395-5881
Mailing Address - Fax:
Practice Address - Street 1:GONZAGA INTERVENTIONAL PAIN MANAGEMENT
Practice Address - Street 2:957 NATIONAL HWY
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-0001
Practice Address - Country:US
Practice Address - Phone:240-362-7128
Practice Address - Fax:240-362-7731
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003577208VP0000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical