Provider Demographics
NPI:1609497346
Name:BOUDREAU, NICHOLAS (CRNA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
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 1:104 FOREST CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-6248
Mailing Address - Country:US
Mailing Address - Phone:954-649-6279
Mailing Address - Fax:
Practice Address - Street 1:104 FOREST CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-6248
Practice Address - Country:US
Practice Address - Phone:954-649-6279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9385003163W00000X
FL11019743367500000X
FLAPRN11019743367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB360633910020OtherDRIVERS LICENSE