Provider Demographics
NPI:1235255712
Name:BOUDREAUX, MARCUS A (FNP)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:A
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5052
Mailing Address - Country:US
Mailing Address - Phone:337-527-6371
Mailing Address - Fax:337-528-2034
Practice Address - Street 1:600 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5052
Practice Address - Country:US
Practice Address - Phone:337-527-6371
Practice Address - Fax:337-528-2034
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA079290APO4239363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1191078Medicaid