Provider Demographics
NPI:1699231894
Name:BOUDREAUX, NICOLE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:34 GATEHOUSE TRL
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-2023
Mailing Address - Country:US
Mailing Address - Phone:410-490-9292
Mailing Address - Fax:
Practice Address - Street 1:12302 SOMERSET AVE STE AB
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-3099
Practice Address - Country:US
Practice Address - Phone:410-651-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007122363AM0700X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0007122OtherMARYLAND MEDICAL LICENSE