Provider Demographics
NPI:1053330738
Name:BOUDREAU, ANDREW GERARD (NP)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:GERARD
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0220
Mailing Address - Country:US
Mailing Address - Phone:906-225-3630
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-4531
Practice Address - Fax:906-225-4807
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704174895363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4958447Medicaid
MIQ74983Medicare UPIN