Provider Demographics
NPI:1639307085
Name:BOUDREAUX, LAURIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:A
Other - Last Name:ARNOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5308 HARROUN RD STE 280
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2190
Practice Address - Country:US
Practice Address - Phone:567-585-2080
Practice Address - Fax:567-585-2081
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200277363A00000X
OH50003687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant