Provider Demographics
NPI:1104544238
Name:BOUDREAU, ELIZABETH JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:866-617-6855
Mailing Address - Fax:503-346-8015
Practice Address - Street 1:3303 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-5058
Practice Address - Fax:503-494-5065
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORPA217617363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical