Provider Demographics
NPI:1093194284
Name:BOUDREAU, RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6955 GOLFCREST DR
Mailing Address - Street 2:APT 1030
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6955 GOLFCREST DR
Practice Address - Street 2:APT 1030
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-2470
Practice Address - Country:US
Practice Address - Phone:240-750-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
1164982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman