Provider Demographics
NPI:1164490116
Name:BOUDREAUX, MELISSA BETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:BETH
Last Name:BOUDREAUX
Suffix:
Gender:F
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1040 RIVER HERITAGE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-6348
Practice Address - Country:US
Practice Address - Phone:941-917-7100
Practice Address - Fax:941-917-7142
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291905200Medicaid
FL291905200Medicaid
Q24528Medicare UPIN