Basic Information
| Provider Information | |||||||||
| NPI: | 1114354495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUDREAU | ||||||||
| FirstName: | CAREY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13811 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191013811 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650077 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 11/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | AA192 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 009792900 | 05 | FL | MEDICAID |