| Doctor Name: | MR. THADDEUS JASON BOUGHTON |
| NPI Number: | 1043553357 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | ANP-BC |
| License Number: | 1139488 |
| Business Practice Address: | 1369a George Wallace Hwy Russellville, AL - 356543281 |
| Business Phone Number: | 2563312615 |
| Business Fax Number: | |
| Mailing Address: | 309 Fulton St, MUSCLE SHOALS |
| State: | AL |
| Postal Code: | 356613669 |
| Phone Number: | 2568564059 |
| Fax Number: | |
| NPI Enumeration Date: | 04/04/2013 |
| NPI Last Update Date: | 05/22/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LA2200X |
| License Number: | 1139488 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AL |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Adult Health |
| Taxonomy Definition: | |