Provider Demographics
NPI:1639852460
Name:BOUCHILLON, LINDA GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:GRACE
Last Name:BOUCHILLON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:BOUCHILLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1448 10TH AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-733-8728
Mailing Address - Fax:304-691-8591
Practice Address - Street 1:1600 MEDICAL CENTER DR STE G500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3659
Practice Address - Country:US
Practice Address - Phone:304-691-1262
Practice Address - Fax:304-691-1666
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant