Provider Demographics
NPI:1730840729
Name:BOUTCHER, BRADLEY SCOTT (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:SCOTT
Last Name:BOUTCHER
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Gender:
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:836 PRUDENTIAL DRIVE
Mailing Address - Street 2:STE 1804
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8345
Mailing Address - Country:US
Mailing Address - Phone:904-398-3888
Mailing Address - Fax:904-400-6675
Practice Address - Street 1:836 PRUDENTIAL DRIVE
Practice Address - Street 2:STE 1804
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8345
Practice Address - Country:US
Practice Address - Phone:904-398-3888
Practice Address - Fax:904-400-6675
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL9115278363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant