Provider Demographics
NPI:1508801853
Name:BOUDREAU, WILLIAM MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
Last Name:BOUDREAU
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 1:43309 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-6221
Mailing Address - Country:US
Mailing Address - Phone:727-943-3111
Mailing Address - Fax:727-943-3334
Practice Address - Street 1:43309 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-6221
Practice Address - Country:US
Practice Address - Phone:727-943-3111
Practice Address - Fax:727-943-3334
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1508292367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0082OtherBCBS
FL033916400Medicaid
FLG0082UMedicare PIN