Provider Demographics
NPI:1063494722
Name:BOUDREAUX, DAVID MICHAEL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N HENNESSEY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3622
Mailing Address - Country:US
Mailing Address - Phone:504-488-1409
Mailing Address - Fax:504-483-3277
Practice Address - Street 1:902 N HENNESSEY ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-3622
Practice Address - Country:US
Practice Address - Phone:504-488-1409
Practice Address - Fax:504-483-3277
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN036422 APO2191367500000X
TX031963367500000X
FLARNP9285473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199945001Medicaid
FL001751800Medicaid
LA1901741Medicaid
TXP00731625OtherRAILROAD MEDICARE
FLCT553ZMedicare PIN
LA56334C734Medicare PIN
TX199945001Medicaid
TX8L7072Medicare PIN