Provider Demographics
NPI:1093597197
Name:CARRERA BOADA, JESUS GREGORIO (SA-C)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:GREGORIO
Last Name:CARRERA BOADA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N LOOP 336 W APT 814
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3691
Mailing Address - Country:US
Mailing Address - Phone:936-320-4210
Mailing Address - Fax:
Practice Address - Street 1:2200 N LOOP 336 W APT 814
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3691
Practice Address - Country:US
Practice Address - Phone:936-320-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23-580246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant