Provider Demographics
NPI:1043553357
Name:BOUGHTON, THADDEUS JASON (ANP-BC)
Entity type:Individual
Prefix:MR
First Name:THADDEUS
Middle Name:JASON
Last Name:BOUGHTON
Suffix:
Gender:M
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E 6TH STREET SUITE E
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3669
Mailing Address - Country:US
Mailing Address - Phone:256-314-2431
Mailing Address - Fax:
Practice Address - Street 1:1110 E 6TH STREET SUITE E
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661
Practice Address - Country:US
Practice Address - Phone:256-314-2431
Practice Address - Fax:256-314-2435
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1139488363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health