Provider Demographics
NPI:1952883605
Name:BOUDREAUX, RAEGEN HARBOUR (PA)
Entity type:Individual
Prefix:
First Name:RAEGEN
Middle Name:HARBOUR
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5262 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-1951
Mailing Address - Country:US
Mailing Address - Phone:225-315-9224
Mailing Address - Fax:
Practice Address - Street 1:1717 SAINT CHARLES AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-5223
Practice Address - Country:US
Practice Address - Phone:504-529-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310483363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical